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Just Culture in Day-to-Day Operations

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Article Information
Category: Human Error
in Aviation
and Legal Process
Human Error in Aviation and Legal Process
Content source: SKYbrary About SKYbrary
Content control: SKYbrary About SKYbrary

Description

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:

Related Articles

Further Reading

Just Culture Awareness Workshop (Barcelona 2017) Presentations