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Just Culture in Day-to-Day Operations
From SKYbrary Wiki
and Legal Process
Just Culture is a culture where front-line operators or other persons are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, willful violations and destructive acts are not tolerated.
Just Culture in Practice
While the formal broad description of just culture is stemming from the EUROCONTROL SAFREP TF (Safety Reporting and Data Flow Task Force) and was picked up by the EU regulations on performance (EU Regulation No 390/2013) and occurrence reporting (EU Regulation No 376/2014), what does it really mean for everyone to apply just culture in daily operations?
We must assume that people set out to do their best – they act with good intent – and organisations and individuals must therefore adopt a mind-set of fairness. This mind-set works at several levels, notably at the level of the individual, the group or team, the organisation, the profession and the nation, and affects the behaviour of persons and the system as a whole. It is worth reflecting on whether you see the human primarily as a hazard and source of risk, or primarily as a resource and source of flexibility and resilience. Each mind-set may take you in a different direction, but the former is more likely to lead to the road of blame, which does not help understand work as done.
The mind-set of fairness will allow us to understand normal work that includes deviations from work as we imagined it, such as:
- Why would a controller allow an aircraft to fly below minimum safe altitude?
- Why would an engineer take an undocumented shortcut?
- Why would a supervisor not take action to ensure aircraft avoid a thunderstorm?
- Why would a controller use equipment she/he is not licenced to use?
- Why would a pilot ignore manufacturer’s manuals and airline emergency procedures?
What seemed like the right thing to do or not do in a particular situation may seem strange or inappropriate in hindsight. While we can’t get rid of hindsight, we can remove some of the bias by trying to see things from the person’s point of view, and by avoiding language that is ‘counterfactual’ and judgemental (about what they could have or should have done).
Just Culture has different facets and dimensions – judiciary, corporate, media and societal. Of course, it should not be limited to aviation industry. Just Culture is equally applicable in everyday life of many high reliability industries, as well as in our personal life.
For more routine situations, assuming goodwill and adopting a mind-set of fairness is a prerequisite to understanding how things work. When people’s actions are understood in context, work-as-done can be discussed more openly with less need for self-protective behaviour.
The principles of Just Culture will allow us also to unravel why:
- A school submitted children to an exam with no preparation?
- A nurse falsifies the time taken for an emergency admission?
- A call centre worker puts the phone down deliberately cutting you off?
Watch the Just Culture in Practice video produced by ENAIRE:
Just Culture Awareness Workshop (Barcelona 2017) Presentations
- Everything You Wanted to Know about Just Culture and Were Afraid to Ask, Marc Baumgartner, IFATCA, 24 May 2017.
- Everything You Wanted to Know about Just Culture and Were Afraid to Ask (continued), Marc Baumgartner, IFATCA, 24 May 2017.
- Just Culture – What It Is and What It Is Not: From the Perspective of Work-as-Done Vs. Work-as-Imagined, Tony Licu & Steven Shorrock, EUROCONTROL, 24 May 2017.
- Judicial system and Just Culture, Florentino-Gregorio Ruiz Yamuza, 24 May 2017.
- “Usage” of the Investigation Report Outside Safety Management Systems, Ian Weston, FRAeS, 24 May 2017.
- Interlab Simulations - Safety culture and Errors, Fabrice Drogoul, EUROCONTROL, 24 May 2017.
- Best Practices in Safety Investigations - How to Write a Balanced Just Culture Investigation Report, Tony Licu, EUROCONTROL, 24 May 2017.
- ENAIRE's Incident Contributors Assessment Procedure, Jesús Romero, ENAIRE, 24 May 2017.
- Example of Day to Day Just Culture: Can we handle Just Culture in an objective way?, Tony Licu, EUROCONTROL, 25 May 2017.
- “A Tale of Two Cities” - Safety and Justice: How the Bridge Must Be Built, Prof. Dra. Irene Nadal Gómez, 25 May 2017.
- How to Open the Link and How to Talk to Media – Practical Just Culture in Day-to-Day Operations Seminar, Alejandra Gil, Aprocta, 25 May 2017.
- Safety Systemic Thinking: How to Look Beyond the Human Error, Guadalupe Cortés Obrero, Aprocta, 25 May 2017.
- Just Culture within the Airlines: The Role of the Expert Experience, Juan Carlos Lozano, SEPLA, 25 May 2017.
- Planteamiento de los procesos penales derivados de grandes catástrofes. Especial referencia al procedimiento derivado del accidente aéreo ocurrido en Madrid el 20-8-08, Lorenzo Bernal Marsallá, 26 May 2017.
- La instrucción judicial en supuestos de grandes catástrofes, y, en particular, de accidentes aéreos, Juan Javier Pérez Pérez, 26 May 2017.
- Just Culture Conversation between Aviation and Judiciary. Occurrence Scenario 1: Landing Confusion, EUROCONTROL, 26 May 2017.
- Just Culture Conversation between Aviation and Judiciary. Occurrence Scenario 2: 3-Way Take-Off, EUROCONTROL, 26 May 2017.
- The Role of the Expert – Practical Just Culture Cases, Toni Licu, EUROCONTROL, 26 May 2017.