SAFETY AND JUST CULTURE
Safety Culture is the way safety is perceived, valued and prioritised in an organisation. It reflects the real commitment to safety at all levels in the organisation. It has also been described as “how an organisation behaves when no one is watching”.
Safety Culture is not something you get or buy; it is something an organisation acquires as a product of the combined effects of Organisational Culture, Professional Culture and, often, National Culture.
Safety Culture can therefore be positive, negative or neutral. Its essence is in what people believe about the importance of safety, including what they think that their peers, superiors and leaders really believe about safety as a priority.
Why is Safety Culture Important?
Safety Culture can have a direct impact on safe performance. If someone believes that safety is not really important, even temporarily, then workarounds, cutting corners, or making unsafe decisions or judgements will be the result, especially when there is a small perceived risk rather than an obvious danger. However, a typical and understandable first response to Safety Culture is:
“We already have an SMS, why do we need Safety Culture too?”
A Safety Management System represents an organisation’s competence in the area of safety, and it is important to have an SMS and competent safety staff to execute it.
But such rules and processes may not always be followed, particularly if people in the organisation believe that, for example, ‘moving traffic’ is the real over-riding priority, even if risks are occasionally taken.
Where would people get such an idea? The answer, ultimately is from their peers, but more so their superiors, including the person at the helm of an organisation, namely the CEO. To ensure the required commitment to safety, organisational leaders must show that safety is their priority.
So, organisations need both a SMS and a healthy Safety Culture in order to achieve acceptable safety performance. But with aviation, there is the problem that it is generally very safe, with serious accident outcomes occurring only rarely. This means that almost all organisations will assume they are already safe. There may be few incident reports, and these may be of low severity; safety cases may be well in hand for current operations and future changes.
Real aircraft accidents are usually complex and multiple causes can be identified, so it is not always easy to see them coming. Even harder to see are contributing situations which affect an organisation’s ‘forward vision’ in safety.
For example, under-reporting of incidents due to fears of recrimination or prosecution; people running risks because they believe that is what they are supposed to do; different sub-groups not sharing information due to a lack of mutual trust; etc.
What Does Safety Culture Deliver
An optimum Safety Culture will delivers a clearer and more comprehensive picture of operational risk, one that takes in all aspects of the activities of the organisation. This is possible through the achievement of a better information flow and the maintenance of an effective dialogue within the organisation about safety performance as priority.
Why Safety Culture Awareness matters
A focus on knowing what the level of safety culture is and striving to achieve a level which is adequate brings a better focus on incident recording, incident analysis, staff training and the integration of maintenance safety and operational safety priorities.
Safety Culture must be seen as a key business target so that the people at the ‘sharp end’ feel empowered to act in the interests of safety in the knowledge that the management will support them. This enhancement of mutual trust is invariably accompanied by a positive impact on productivity.
Each organisation is different and each will also have its own national culture as a business environment, so the both the methods and the opportunities for achieving organisational safety culture will vary. However, the insights achieved by regular measurement of safety culture and the use of the results to identify where improvement effort must be targeted is essential.
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 behavior.
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.
Conditions for Just Culture
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
Hence, a Just Culture supports learning from unsafe acts in order to improve the level of safety awareness through the improved recognition of safety situations and helps to develop conscious articulation and sharing of safety information. Consequently, a Just Culture can be regarded as an enabler, and even indicator of, (a good) Safety Culture.
Statement Outlining 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:
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 permission 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.
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.
Loss of License
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 license. Such action must never be punitive.
Key Features for Developing and Maintaining a Just Culture
The following list oultines some of the key features that need to be addressed when developing and maintaining a Just Culture in an organisation:
- Just Culture policy documented.
- Definitions agreed about what is “acceptable” behavior, and what is “not acceptable”. (Note: these will be specific to, and aligned with, values derived from national, organizational and professional cultures).
- Sanctions agreed for unacceptable behavior.
- Process to deal with actions in the “grey area”.
- Just Culture policy communicated throughout the organisation.
- Reporting systems linked to Just Culture policy.
- Fair treatment being applied.
- Breaches of the policy being monitored (e.g., error punished or violations excused).
- Reports being followed-up; actions taken to address error-producing conditions.
All of the organisation’s staff have their own responsibility to act safely in whatever they do. They are responsible for their competence in the job and fitness for duty. Where appropriate, they carry a license. They act in accordance with their training and professional standards for their job. They adhere to written procedures. If, in the interest of safety, it is necessary to deviate from procedures, they will do so and give full account. They show teamwork and actively support co-workers during their services wherever appropriate. If unexpected things come up, even events that (nearly) go wrong in which they are involved, they are keen to take responsibility and learn what they might have done wrong so they can improve and the system can improve.
In the organisation all of the staff is appreciated as the most value-adding asset. They fill the discretionary space with cannot be reached by systems or procedures, and their capability to decide, judge and act is essential to the working of the whole system. The organisation provides them with the right environment, the right tools, the right training and the right procedures that are necessary to perform the job. Never is the staff brought into situations that could be harmful to them or others.
The personnel is clear, that in the interest of safety, the organisation wants to know, at all times, about unsafe events, unsafe situations that have presented themselves or could arise. They are keen to step forward and speak up when they perceive a situation as dangerous, think of a procedure as risky, or any other issue in their daily tasks that they judge as potentially harmful and is yet without good remedy. This specifically includes any situation or event that involves themselves.
When mishaps do occur, the organisation attempts to repair the situation as best as possible and restore the operations to normal. The organisation provides compensation for those that have experienced personal loss or damage. The organisation tries hard to prevent that same event from happening again. A case is not closed by condemning or finding the guilty one, but by discovering the underlying problems in the system, by rectifying this and by repairing the damages done. Everybody participates in this effort.
Protection and support
When it becomes apparent that staff has made an error, the organisation will neither assume nor seek personal fault or guilt. There is a strong belief that punishment is counterproductive to safety. The organisation investigates why this error was made and what can be done to avoid them or to mitigate the effects for future operations. The workforce is protected as best as possible from negative consequences resulting from human error or subsequent investigations and in principle the organisation will defend and support people should external prosecutions or litigations target them.
No tolerance for unacceptable behavior
The above statements do not mean that ‘anything goes’. The organisation does not tolerate gross negligence, deliberately unsafe acts or recklessness from the staff, regardless of the outcome. There is constant discussion with the staff what the right professional behavior is for their jobs and where the boundaries of tolerated and non-tolerated acts are. The organisation leaders and staff agree about what the consequences are if these norms are crossed.
Just Culture in Practice
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 behavior 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 licensed 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 judgmental (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 behavior.