February 23, 2020 – It’s Just Culture

Parking Ticket

February 23, 2020
Editorial Team
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Rachel has an appointment downtown at 9:30am. She arrived a few minutes early and was thrilled to find a metered parking spot on Main Street, right outside of the office building.

Rachel walked to the meter and saw that the parking fees were only in effect from 10am-8pm. Her appointment would last at least 1 hour, so although she wasn’t required to pay until 10am, she attempted to pay early. In her mind, it was smarter to pay a $0.75 extra now, and completely avoid a parking ticket.

She inserted her credit card, but saw the following message: “Meter starts at 10:00am.” She ran across and down the street, trying two other meters. All gave the same error message. Try as she might, the meters would not begin accepting money until exactly 10am – the time when fees would be enforced.

The meters would not accept money until exactly 10am

Rachel was frustrated. She remembered back to her friends’ tales of parking tickets past and was trying to avoid the same fate. At that point, her appointment was about to start and instead of moving her car to a side street without meters, she made the decision to leave her car there, without paying. She made a mental note to excuse herself from the meeting at 10am to pay the parking meter.

The meeting went very well! In fact, the team was so engaged that Rachel didn’t look at her watch the entire time. She forgot all about the parking meter drama and emerged from the office building an hour later. There was a parking ticket waiting on her windshield; it was written at 10:11am.

Just Culture Breakdown

Rachel wanted to pay the meter, and she had intended to, but she forgot. She became mentally immersed in the meeting. It’s not as if she remembered the meter at 10am but made the decision to stay. Rather, she became immersed in her work and completely forgot. Rachel’s experience was that of human error. If Rachel has to return to this area, she could consider setting an alarm to remind herself of the time. She could also locate an alternative parking solution.

But that’s also not the full story. This issue was also partially due to an underlying system failure. If parking meters were to accept payment prior to the fine/ticket time, patrons could pay in advance and enter neighboring businesses prior to 10am without having to worry about tickets and fees.

Missed Delivery

February 23, 2020
Editorial Team
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Once a year, I place an order from a family-owned farm on the opposite side of the country. Their animals are raised with love, then they dry-age and freeze their meat… Their company is amazing and it makes for great meals!

I placed the order on Sunday and received a confirmation email later that night. The tracking # would be sent in an additional email when the package shipped (overnight, with dry ice) on Monday or Wednesday. It’s a delicate game with these packages – they need to be opened immediately upon delivery and unloaded into the freezer after their cross-country journey.

By Thursday, I still hadn’t heard anything, so I walked down to the mail room and the package was there, waiting. I rushed it up to the apartment only to find that everything inside the box had thawed and was now room-temp. The box shipped Monday, was delivered Tuesday, and it was now Thursday. The entire order was inedible!

I was so upset – how did this happen?? Investigation revealed that the one email my spam filter mistakenly snared was the email with the tracking number, sent Monday morning. #systemfailure

On a hunch, I reached out to the company owners. Apparently this has happened with more of their customers lately. They sent a replacement order within days, free of charge.

The replacement order – arrived in perfect condition!

To address the underlying system failure, they now ask customers to add the company’s email address to their contact list (a short-term bandage) while also evaluating options for the shipment alerts to evade spam filters. Great customer service, made possible by Just Culture in Action!

Car Crash

February 23, 2020
Editorial Team
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One of our staff members was recently in an accident. While she was lucky to be OK, the result could have been catastrophic. She reflected that it was difficult to restrain herself from getting angry simply over the amount of damage (harm) without knowing any other context. It reminds us that everything falls under a Just Culture.

Here are some different accident scenarios through the lens of a Just Culture…

You are driving home after spending an evening with friends. While moving through an intersection, you hear a horn, then feel the impact. Someone has driven through a red light and hit your car.

The car that hit you had this signal – a red light.

Deliberate harm: If the person wanted to hurt you – if he gunned the engine because he saw my your moving through the intersection and wanted to damage it.

Incapacity: If the other driver had been drinking, that may have slowed his reflexes so he couldn’t stop in time when the light turned red. Or perhaps he was exhausted after having to work 4 straight overnight shifts and fell asleep, cruising through the red light.

Straight-Up System Failure: Have you ever been to an intersection where the lights are turned so that you cannot tell which color is for you and which color is for the intersecting street? If you can see Red and Green lights from your lane, which do you obey? This is a great example of a system failure.

Human Error: The driver was distracted by a conversation in the car, and didn’t see the light turn yellow.

At-Risk Behavior: The driver saw the light turn yellow, but thought he could make it through the intersection in time. He didn’t see any other vehicles waiting at the light, and had done this many times before without issues – he drives this way home every day. He simply misjudged it this time.

Reckless Behavior: The driver is frustrated at having to stop at so many lights on the way home. He sees the light turn yellow and although he knows the parked cars obstruct his view of any other vehicles, he thinks “if anyone else is coming through, they will see me and stop.” He stomps his foot on the gas while loudly venting his frustration.