First seen on the corporate level more than two decades ago, and later embraced by airlines, the concept of a “just culture” in a business aviation flight operation is still building across the industry.
In a just culture, employees are encouraged to report mistakes to an assigned investigative entity within the company, which then feeds that data into the flight operation’s safety management system (SMS). People are not punished for decisions made in good faith, although instances of gross negligence, willful violations and destructive acts are not tolerated.
“The basis of a just culture is trust, and that must come from the top-down,” said a safety manager for the flight operation at a Fortune 500 company. “Personnel must feel safe exposing their errors, so we may openly discuss those situations and identify trends that we may then address and mitigate.”
“To really manage safety proactively, we need to know about situations or events that don’t lead to an accident or incident,” added retired industry safety expert William Grimes. “A just culture is about feeling comfortable enough to raise your hand and admit, ‘this is what I did today.’ It may be embarrassing, but you need an atmosphere that allows mistakes to be made, without retribution. The alternative is to wait for accidents to happen.”
“To really manage safety proactively, we need to know about situations or events that don’t lead to an accident or incident.”
William Grimes Business Aviation Safety Expert
“You must walk the talk,” agreed a maintenance director based in the Southeast. “Flight department leaders and their superiors must be the first ones willing to step up and acknowledge their mistakes and demonstrate the reporting of honest errors will not be met with any negativity.”
While more traditional investigative methods – and company cultures – may have focused on the person or people responsible for mistakes, a just culture emphasizes a non-punitive approach to instead identify such issues before they develop into a potential accident or incident. “A distinct line must be drawn between what was an acceptable, accidental error, and those errors that stemmed from not acceptable behaviors,” the safety manager said. “It’s not a ‘get out of jail free’ card.”
Kent Stauffer, vice president of quality, safety and technical programs for Constant Aviation, said he first saw signs of a just culture developing within business aviation around the 2008 recession.
“As companies were forced to become leaner and more efficient, mistakes that may have been buried in the past came to the surface, even as the people left were usually the best of the best,” he said. “Suddenly, the most senior people were making the most egregious errors, and we needed to understand why.”
Changing from “Who?” to “How?”
The concept of a just culture in aviation stems from aviation safety action programs (ASAP) enacted by airlines in the late 1990s, as well as from the FAA’s Global Aviation Safety Network (GAIN) data gathering and aggregation initiative. More recently, flight operational quality assurance (FOQA) programs are focused on a similar approach to sharing de-identified safety data to recognize potential trends that could lead to accidents.
“It’s about developing an environment where people are comfortable sharing their honest errors,” said the maintenance director. “Any information that helps us learn from our experiences and the experiences of others is valuable.”
To evolve a company’s culture into a just culture, the safety manager emphasized the focus must be on fact-finding to determine the chain of events leading up to the error. One method to help delineate between accidental and reckless behaviors is to develop what he termed a “culpability matrix.”
“It’s about developing an environment where people are comfortable sharing their honest errors.”
A maintenance director for a Southeast-based operator
“In my experience, these situations will usually involve an at-risk choice; someone made a bad decision thinking they were in a safe place,” he said. “We ask ourselves if any other pilot could get into the same situation.”
However, it’s equally important in a just culture that risky or reckless actions still be met with some form of discipline.
“You must have an agreed-to policy detailing how these situations will be handled,” said Grimes. “Management must clearly outline the steps involved, and it’s very important that leadership understands how it works as well.”
“The first step is establishing the right questions,” added the maintenance director. “Shift the emphasis to ‘What happened?’ instead of ‘Who did this?’ All communication shuts down when a ‘who’ is involved.”
As more people within the flight operation buy into the just culture, the safety manager said, others will be convinced. “It kind of takes a village,” he said. “There’s a certain amount of applied pressure when you see others participating in a just culture and it’s clear the environment is non-punitive.”
While the industry has made progress toward adopting a just culture mindset, “it seems that either everyone wants to forgive, or everyone wants to fire,” Stauffer noted. “It’s always a challenge to find the accountability middle, where the focus is truly on addressing behavior and not the outcome. As an industry, we have come a long way, but aren’t quite there yet.”
“Too often, the knee jerk reaction is to ‘do something,’ which sometimes means retribution or even firing the employee,” agreed Grimes. “A just culture cannot be personal, or that will destroy it.”
Walk the Talk
Another key to building a just culture is to ensure the process is carried out uniformly and transparently.
“The only way to bring people into the fold on a just culture is by making it visible to all that you practice what you preach,” Stauffer said. “The worst thing you can do is to accomplish everything behind the scenes so that no one knows about or understands the process.
“You must walk the talk,” the maintenance director agreed. “Flight department leaders and their superiors must be the first ones willing to step up and acknowledge their mistakes and demonstrate the reporting of honest errors will not be met with any negativity.”
That may be difficult for older employees to accept at first, particularly when it’s apparent some employees are favored, or treated with a lighter touch.
“We had a few “old school” people who just weren’t a good fit for the just culture,” the safety manager said. “They eventually wound up leaving the company, but everyone else ultimately embraced it.”
“The only way to bring people into the fold on a just culture is by making it visible to all that you practice what you preach.”
Kent Stauffer Vice President of Quality, Safety and Technical Programs, Constant Aviation
“Every organization has a cultural history,” added the maintenance director. “It’s hard to build trust when mistakes are not handled evenly across the organization, and trust is everything in a just culture. It’s vital that everyone see that honest errors can be reported and, rather than chastised or embarrassed, you will be embraced and perhaps even rewarded by seeing processes changed for the better.”
Employees must also see the just culture mindset “baked into” the flight operation. “When I was a line pilot, I wasn’t thinking SMS every day,” Grimes said. “I was just doing my job, which is why a just culture mindset must be an integral part of the operational culture, right there with customer service and standardized operational processes.”
“Even to this day, much like SMS, a lot of people talk about it and even put it in their manuals, but they don’t really live it,” the safety manager concluded. “A just culture must be embraced; you need to talk about it from the top down, and unless it’s supported in the C-suite, it won’t be believed or trusted. If you don’t have trust, you won’t ever have a just culture.”