Foreword
A massive amount has been written about ‘Just Culture’. As valuable as the theory behind it is, the application of just culture is far from simple at times. We are instinctive creatures, prone to making assumptions and to exerting bias in our relationships with others. We all work under time pressure and – therefore – at times that pressure encourages us to seek the speediest response to an event. What the practitioner needs is absolute simplicity; not just for the sake of ease of application but also for ease of understanding on the part of all personnel.
In no way is this article intended to be a step-by-step guide to the design and implementation of a just culture. Instead, I am – very briefly – sharing some of my own thoughts on what I have observed during my career to date; in both military and civilian service and across numerous cultures.
At the end of this article, I have listed some of the sources I have consulted over time.
The Purpose of Just Culture
No safety management team can stand alone. They all rely on every single employee – whether they be directly involved in safety / operational management or not – to act as the ‘eyes and ears’ of the safety management function. A ’holistic’ approach to safety management is the superior, and the most practical, approach. A safety management system is most effective when it is proactive. A ‘just culture’ is vital to the maintenance of an active safety reporting system.
The following is a wonderful synopsis of the purpose of a just culture:
‘It is therefore fundamentally important to encourage the development of an environment in which occurrences are reported and the necessary processes for investigating and developing preventive action (such as re-training, improved supervision, etc.) are put in place’.
Scource: EUROCONTROL (http://www.eurocontrol.int/articles/just-culture).
Principles
The following is an excellent discussion of the topic:
The most important tool in a proactive safety management system is safety reporting. This should, always, include the reporting of hazards as well as events. Not only is it incorrect but, also inappropriate, to believe that only persons assigned specific roles or with specific experience are capable of noting hazards. Every single employee is capable of taking a decision that affects – adversely or not – the ability to manage an operation. Everyone has a role, is a specialist in that role, and deserves to be respected for having an opinion. Every decision that takes eyes off the operation should be considered a negative one. Every administrative requirement carries with it a workload requirement and the time has to come from somewhere; administration should not be treated as completely separate from operational management. The list is long.
The Decision Process
In all organisations, there exists a need for consistency in the application of a just culture. In practice, the SMS manual should contain a simple guide to the decision process.
There are many flowcharts available; I like this one for its simplicity:
Scource: https://www.icao.int/APAC/Meetings/2018%20APRAST12/APRAST12%20WP-11%20AI_5%20-%20%5BNokScoot_AEROTHAI_CANSO%5D%20Just%20Culture.pdf.
Just culture does not mean the complete protection of individuals in the event of an occurrence. However, just culture IS based upon the assumption that personnel can make a mistake and only an independent, diligent determination and unbiased decision process can separate an ‘honest mistake’ (see below) from reckless / intentional behaviour.
One explanation of ‘honest mistake’ can be found at Regulation (EU) 376/2014 (on the reporting, analysis and follow-up of occurrences in civil aviation) which states, at Item (37) of the Preamble, that an individual should not be subject to prejudice:
‘except in cases of wilful misconduct or where there has been manifest, severe and serious disregard with respect to an obvious risk and profound failure of professional responsibility to take such care as is evidently required in the circumstances, causing foreseeable damage to a person or to property, or seriously compromising the level of aviation safety’.
No flowchart can, possibly, be fully-descriptive of the process by which any incident can be analysed. However, the above expresses in very simple terms the principles that should be adopted. Nevertheless, there remains potential for inconsistencies arising from the ‘human element’.
The Human Element
Often, the working culture within an approved organisation is a reflection of the culture of the State in which it is located; of the State from which most of its employees are drawn. In such situations, in which senior managers might be drawn from a number of non-State cultures, it becomes even more difficult to adjust to local, cultural norms. Having worked for approved organisations in numerous countries, and having been raised in two cultures, I speak from experience.
A ‘just culture’ cannot, simply, be switched on when it might be needed. A just culture is the product of everyday actions, thoughts, comments, attitudes; it is about creating an expectation of fairness, the even-handed treatment of personnel and the absence of bias. It is about day-to-day communication and the absence of fear that a mistake, in one’s own opinion, does not carry an increased risk of losing one’s job (especially during a time of heavy staff cuts). In other words, it is about a lot more than procedure and policy; it is, actually, a lot more to do with working culture, management style and trust in personality. Trust in personality cannot be the product of managing from behind one’s desk; it needs to be created by a ‘personal touch’, to a certain degree. The old adage of ‘walking the shop floor’ always holds true.
I propose some basic considerations:
- Create an expectation of ownership, value of individual contribution and of respect for opinion;
- Allow and praise initiative;
- Resist micro-managing (it engenders a culture of lack of respect for role, experience and personal qualities);
- Encourage auditees to identify root cause and design effective preventive actions;
- Select and develop your ‘champions’ of just culture;
- Encourage active hazard reporting and use workshops, citing real-life examples rather than examples of theory, to teach personnel what about its value.
Further Reading
Various, ‘Fostering Just Culture in Operators and Service Providers‘ https://www.icao.int/APAC/Meetings/2018%20APRAST12/APRAST12%20WP-11%20AI_5%20-%20%5BNokScoot_AEROTHAI_CANSO%5D%20Just%20Culture.pdf.
EUROCONTROL, ‘Finding the right balance between the aviation, judicial and political authorities‘ https://www.eurocontrol.int/initiative/just-culture.
EUROCONTROLTV, ‘Just Culture: Because we are all Humans‘ https://www.youtube.com/watch?v=4Y5lRR9YK2U.
Footnote:
Should further information be required, including a .pdf version of this article, please contact the Author.