What is a "Just Culture"?

I found the following article in this weeks issues of the Human Factors Industry News. Being old school (more PC than the Dinosaur tag tossed my way at times) I am shocked at the lack of personal responsibility and the "blame" mentality we find around us. This article talks about changing blame mentality to improve your safety program.

Bob Jones

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In many workplaces people are hesitant to take notice
of, or speak up, about conditions that cry out for
improvement. People are especially reluctant to report
errors made by others. Don't even think about someone
reporting his or her own error. In recent generations our
society has taken on a "blame culture" that always
wants to point the finger at someone else. When
someone is found to be responsible for a condition that
should not exist, blame and retribution follow. In that
environment people do not want to single out their
friends and coworkers, much less themselves. Thus,
the "See no evil, hear no evil, speak no evil" approach to
personal and work relationships is widely practiced.

Although the blame culture is antithetical to a strong safety culture, it continues to exist even at organizations that have implemented a Safety Management System. The SMS relies on reporting errors and conditions to detect hazards, assess the associated risks, and devise policies or procedures to mitigate those risks. Certainly errors and conditions exist that deserve to be reported so they may not be repeated, but reports are unlikely to come in if blame and retribution will be the result.

Enter the concept of "Just Culture." A just culture is one in which personnel feel free to report errors and conditions — even their own errors — without fear of the bounce back upon themselves or their coworkers. In a just culture such reports would be met with, "Thanks for your input. Tell me a little more so we can be sure
we come up with the right solution." Reports are solicited as a way to continuously improve the Safety Management System.

A just culture enhances and strengthens the SMS. Yet, while training
organizations around the world, frequently find many that do not have a policy to promote just culture, much less practice it. Most people are not even familiar with the term. It is not mentioned in the IS-BAO audit protocol, nor directly referenced in supporting material. This must change, as the concept is a critical facet of
SMS.

While the submission of safety reports is an obvious application of just culture, the concept impacts the use of all of the tools in the safety toolbox. It encourages complete and accurate reporting of findings on internal audits, policy waiver procedures, and change management. I frequently talk to people who fill out an incomplete risk assessment form because they "don't want to ring the bell." But
that's what the SMS is all about! Report accurately, and then deal with the consequences. It is the condition itself that is important, not what you have to say about it.

If you are thinking that Just Culture is equivalent to a No Blame Culture, think again. We do hold people accountable for their actions and their decisions. But rather than assigning blame, we are seeking to identify shortcomings in the system that led to or enabled mistaken action.

Furthermore, Just Culture is NOT a "get out of jail free" card. It should not and will not absolve the person who engages in a willfully unsafe or illegal act, nor the individual who repeatedly shows disregard for established procedures. Such people do need to be dealt with severely.

If this is a new idea to you, talk it up with your management. They must fully support the concept. If a blame culture has existed in your organization, it will take time for managers and employees alike to trust the new system. But it won't be long before Just Culture is part of your organization's nervous system.

For a more comprehensive report on Just Culture check out http://flightsafety.org/files/just_culture.pdf.

Comments

Bob this is a great article especially for those FBOs that aren't a CRS. The lesson to be learned here by all is that the FAA really is here to help you [yeah, yeah, yeah...]. The point is you must have a good working relationship with your FSDO and have a level of trust that only comes from working WITH your Feds. But let's not overlook the fact that this attitude must start within your company and that begins at the top.

As they say, hindsight is 20/20. It's easy to point out blame after the fact when what we really need to do is avoid the incident all together and that's done thru education, training and practicing safe work habits. The inherent pressures of aviation notwithstanding, it's up to the individual techs to make this happen. As I have said many times before, you are your own quality control...

I am definitely referring this blog to my friends and family. It was very informative, and I think everyone should read it.

This is a great article and I can honestly say I have never heard of "just culture" before. This was very enlightening for me. SMS at my company is only a powerpoint presentation where we are expected to memorize the key points.