If you are ever happened to be in Washington DC a few years ago and you were going to ride the Metro, you may have had the opportunity to use (or watch other try to use) the machines that would give you your Metro card (they use different machines now). It was really interesting to try and figure out how to use these machines. Now imagine if you were from a different country and didn’t know speak English.
The picture shows the machine that you need to interact with to get your Metro card. No card….no get on the Metro. But if you need something as important as a Metro card, it seems like it might be nice to make certain that it is easy and intuitive to get that card.
That machine was very hard to figure out. The first (and second time I used it) I really struggled to use it. Now maybe it was me, but maybe it wasn’t. Mistakes and terrible errors sometimes happen, not because people are bad or stupid, but because we design systems that are hard for people to figure out. This might be sort of amusing in the Metro, but it can be lethal in other important industries (like healthcare). But as it turns out it is really hard to design intuitive equipment for people to interface with. Really hard. But when people fail to be successful interacting with complicated machinery (or systems), we need to try and understand the problem, not just place blame. When we blame people or fire them, the system problem remains. Someone will likely fail in that system again because we never fixed anything.
This is what the Just Culture is about – not blaming people for being human.