Just Culture
Just Culture is the latest movement in aviation that promotes humanity, personal approach, and in-depth study of the root causes of problems that occur in the industry. Today we will discuss in more detail what this concept means
Just Culture
Reading time: ~5-7 minutes
A Just Culture has been defined as a culture in which front line operators and others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.
What'll we discover today?
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Definition of Just Culture
One key to the successful implementation of safety regulation is to attain a “just culture” reporting environment within aviation organisations, regulators and investigation authorities. This effective reporting culture depends on how those organisations handle blame and punishment.
Only a very small proportion of human actions that are unsafe are deliberate (e.g. criminal activity, substance abuse, use of controlled substances, reckless noncompliance, sabotage, etc.) and as such deserve sanctions of appropriate severity. A blanket amnesty on all unsafe acts would lack credibility in the eyes of employees and could be seen to oppose natural justice. A “no-blame” culture per se is therefore neither feasible nor desirable.
What is needed is a “just culture”, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information - but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
What is needed is a “just culture”, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information - but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
There is a need to learn from accidents and incidents through safety investigation so as to take appropriate action to prevent the repetition of such events. In addition, it is important that even apparently minor occurrences are investigated, in order to prevent catalysts for major accidents.
Safety analysis and investigation is a necessary and effective means of improving safety, by learning the appropriate lessons from safety occurrences and adopting preventative actions. It is therefore important that an environment exists where occurrences are reported, the necessary processes are in place for investigation and for the development of necessary preventative actions such as re-training, improved supervision etc.
Safety analysis and investigation is a necessary and effective means of improving safety, by learning the appropriate lessons from safety occurrences and adopting preventative actions. It is therefore important that an environment exists where occurrences are reported, the necessary processes are in place for investigation and for the development of necessary preventative actions such as re-training, improved supervision etc.
Under “Just Culture” conditions, individuals are not blamed for ‘honest errors’, but are held accountable for wilful violations and gross negligence.
People are less willing to inform the organisation about their own errors and other safety problems or hazards if they are afraid of being punished or prosecuted. Such lack of trust of employees prevents the management from being properly informed of the actual risks.
Managers are then unable to make the right decisions in order to improve safety. However, a totally “no-blame” culture is neither feasible nor desirable. Most people desire some level of accountability when a mishap occurs.
And through mistakes we learn to become someone better.
Managers are then unable to make the right decisions in order to improve safety. However, a totally “no-blame” culture is neither feasible nor desirable. Most people desire some level of accountability when a mishap occurs.
And through mistakes we learn to become someone better.
Integration of Just Culture
People are understandably reluctant to report their mistakes to the organisation that employs them or the government department that regulates them. To encourage them to do so, these organisations should publish statements summarising the fundamental principles of a just culture which they will follow. Additionally, they must ensure that these principles are applied at all levels of their organisations.
Such a statement should cover the following matters:
Such a statement should cover the following matters:
1
Confidentiality
People are reluctant to draw attention to errors made by themselves or their colleagues, due to personal embarrassment. They must be confident that their identity, or the identity of any person implicated in the report will not be disclosed without their permision or unless this is required by law. An assurance should also be given that any subsequent safety action taken will, as far as possible, ensure the anonymity of the persons involved.
2
Punitive Action
A person who breaks the law or breaches a regulation or company procedure through a deliberate act or gross negligence cannot expect immunity from prosecution. However, if the offence was unpremeditated and unintentional, and would not have come to light except for the report, he/she should be protected from punishment or prosecution.
3
Loss of Licence
The circumstances of a report may indicate that the performance of an individual is below the acceptable level. This may indicate the need for further training, or even cancellation of an individual's licence. Such action must never be punitive.
Key Features of Just Culture
The following list oultines some of the key features that need to be addressed when developing and maintainng a Just Culture in an organisation:
1
Just Culture policy documented
2
Definitions agreed about what is “acceptable” behaviour, and what is “not acceptable”
3
Sanctions agreed for unacceptable behaviour
4
Process to deal with actions in the “grey area”
5
Just Culture policy communicated throughout the organisation
6
Reporting systems linked to Just Culture policy
7
Breaches of the policy being monitored (e.g., error punished or violations excused)
8
Reports being followed-up; actions taken to address error-producing conditions
By implementing and maintaining these points, any company can change for the better. Where pilots and staff used to hide violations and try to cover up complex issues, people will start improving their professional skills, reporting risks and problems - all because of a humane and fair approach to them.
Summary
Being a professional does not mean never making mistakes. We are all human, and in difficult moments we may lack the experience or internal resources to make the right decision. But we are not alone in this industry, and most often other elements of the system will not allow our mistake to lead to anything terrible.
Therefore, there is no need to be afraid of mistakes. Fair culture is already being applied even in our Russian companies, and voluntary reports on deviations in flights no longer threaten pilots with dismissal or even sanctions. Together we can improve our industry, move forward and become better - while treating each other humanely and carefully. And we know how to admit our mistakes :)
Therefore, there is no need to be afraid of mistakes. Fair culture is already being applied even in our Russian companies, and voluntary reports on deviations in flights no longer threaten pilots with dismissal or even sanctions. Together we can improve our industry, move forward and become better - while treating each other humanely and carefully. And we know how to admit our mistakes :)
Name of article: Just Culture
Release date: 8/31/2023
Acrticle author: Nikita Pavlov
Release date: 8/31/2023
Acrticle author: Nikita Pavlov
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