Just Culture, 3rd Edition

3	Safety Reporting and Honest Disclosure

A basic premise of a just culture is that it helps people report safety issues without fear of the consequences. It is almost an article of faith in the safety community that reporting helps learning, and that such learning helps improve safety. This seems borne out by the many incidents and accidents that, certainly in hindsight, seem to have been preceded by sentinel events. There is an implicit understanding that reporting is critical for learning. And learning is critical for improving safety (or, if anything, for staying just ahead of the changing nature of risk). The safety literature, however, has been modest in providing systematic evidence for the link among reporting, learning, and safety—if ...