Just Culture: Strengthening Business Aviation Safety Through Trust

Employees need to be able to admit mistakes without fear of reprisal. That concept is the basis of how a just culture is created and safe business aircraft operations are held to the highest possible standards.

In fact, the rise of just culture, together with robust FAA/industry educational outreach and training, has significantly contributed to lower general aviation incident and accident rates. In 2023, the GA fatal accident rate was just 0.762 per 100,000 flight hours, down from 1.118 per 100,000 flight hours in 2013. In the first 10 months of 2024, the rate of serious runway incursions fell by 73% compared to the same period in 2023.

In a just culture, employers create an environment where employees are encouraged to report mistakes to a designated investigative body within the company. The information is then integrated into the flight operation’s safety management system (SMS). Although staff are protected from punishment for decisions made in good faith, cases involving gross negligence, willful violations or deliberate harmful actions are not exempt from accountability.

“One of the reasons I’m drawn to safety is that every day is harder than yesterday in terms of making gains,” said Antonio I. Cortés, Ph.D., an aviation safety expert at GMR Human Performance. “Just culture is an attempt to take what’s already there in SMS and other safety tools and enhance effectiveness. Hopefully, your flight department is looking for new interventions for threats and errors and, at the same time, rolling out a just culture environment – empowering and encouraging people to report dangerous situations, hazards and errors.”

An 'Ongoing Journey’

The foundation of a just culture is trust. Building trust relies upon clear, constant communication across all levels of an organization, said Rob Lewis, aviation safety officer at Jack Henry, who served as safety coordinator for almost 15 years and is still active in maintaining the company’s SMS.

“It’s definitely a constant, ongoing journey and it evolves over time,” Lewis said. “You may have one instance where someone is unhappy because their safety report wasn’t answered the way they expected, while the rest of the department is perfectly fine with it. Now, you’ve got one dissatisfied person.”

The challenge is making sure, as an organization, you are chasing that moving target. This means reassuring the individual who feels unsatisfied that the system is working, that it’s moving forward, and that the process must continue, said Lewis.

“All employees should understand that when you file a safety report or have a conversation with your manager, sometimes things won’t go the way you’d like. But it’s important to recognize that it’s for the greater good,” Lewis said. “Your concern may not be resolved right away, but with strong communication and persistence, there’s a good chance it will eventually evolve into an outcome that works for you.”

Evolving Risks

Strong communication is essential for mitigating impacts of evolving risks, said Kevin Honan, director of product development at Nimbl. Formerly known as AviationManuals, Nimbl supports more than 4,000 operators worldwide with international procedures, regulatory updates and more.

New technologies can be invaluable tools, but they also bring huge potential challenges. Data breaches, ransomware attacks and malware can pose possible threats. Making sure every employee understands the risks is key to safeguarding against them.

“Communication is the important element here; making sure your data security policies are communicated in a way that makes sense in their day-to-day workflows helps with buy-in,” said Honan. “It is also beneficial to explain the reasons why these policies are put into place, to show that the changes come from a real threat rather than a change just for the sake of it.”

Data-Based Learning

Craig Erickson, safety programs manager at San Francisco Bay Area-based aircraft management and charter sales firm Solairus Aviation, said the company is able to use data to improve its just culture and operational safety in ways that were not possible five years ago.

“We went through the top-25 airports and areas that we fly into and [focused on] the top five. Then we started looking at our risk analysis for every flight and how that intersects with where we’re operating,” said Erickson.

The No. 1 risk assessment item that Solairus pilots and flight crews mark off is landing below Class B airspace at smaller airports. “Coincidentally, that is where we also found that most of the reports for a near-miss event are coming in.

“So now we can go back out to our flight crews and say, ‘If you’re going into this certain environment or this airport or underneath the Class B airspace, you should be aware that your risk going into those areas is higher.’ This, in turn, improves the situational awareness of our crews,” said Erickson.

Remote Working Challenges

But how can teams continue to communicate effectively when working remotely? It can become easy to lose those important people skills when working in relative isolation, and that can cause complications regarding a company’s culture.

During the pandemic there were some attempts at trying to patch this, such as remote happy hours, but some teams found those to be awkward and forced, said Honan.

In-person events, such as those offered by NBAA, are a good tool for combating isolation. “I highly recommend getting involved in your local business aviation association, as they have great discussions and educational opportunities,” Honan explained. “They are also a great place to have face-to-face conversations to discuss challenges and successes, and also a great melting pot of ideas that can prove very valuable.”

It’s important to have regular, effective check-ins and training with account managers at each operating location. “This is to make sure that, No. 1, they have that direct lifeline back to the head office and are checking in regularly with their point of contact,” said Erickson. “We also have a consistent message coming out of the head office across the organization.

“A consistent message is really important, especially in a decentralized and global model like we have,” Erickson added.

Measuring Just Culture Health

While the challenges of maintaining a just culture continue to evolve, so do the processes used to measure its health. Maintaining personal communication with all staff members is key. “You have to because once you start losing your connection with your employees, that’s when people can start filling in the blanks, damaging the culture,” Lewis said.

Also, consider using NBAA’s safety culture survey to assess your organization’s just culture. “These surveys, typically conducted anonymously, ask employees a variety of questions, ranging from their opinions on the company’s safety policies to whether they feel their safety submissions will be met with reprisal,” Honan said.

Instances of active participation and listening by management personnel are also helpful metrics. Honan said software-based SMS like Nimbl can demonstrate this, tracking metrics such as user login frequency information and management communications.

“A just culture is demonstrated from the top down and, if management is actively involved and speaking with their employees on safety matters, being transparent on safety initiatives and demonstrating commitment, it goes a long way to building a strong safety culture,” said Honan.

Use Data When Reporting to C-Suites

Entering the conversation with data from safety systems typically helps when reporting to C-suites, Honan said, whether it be information from safety performance indicators showing a reduction in a certain type of error, or newly identified threats that have been mitigated.

As an example, Honan described a crew member’s honest report of an unsafe towing practice. The report may have prevented a ground handling accident with potential damages valued in the six-figure range.

Fear = Higher Risks and Costs

According to NBAA Director, Safety and Flight Operations Mark Larsen, CAM, demonstrating value to company executives ties into a broader effort to communicate the overall value of an organization.

“Without a just culture, companies often resort to punitive measures, such as firing employees after mistakes,” Larsen said. “With today’s shortage of qualified aviation professionals, the cost of losing a trained employee has risen sharply.”

Replacing an employee brings significant direct and indirect costs. When employees fear punishment, issues may be hidden instead of addressed, creating greater long-term risks and expenses.

Larsen noted that organizations embracing just culture often frame it in financial and strategic terms, showing leaders that while mistakes carry short-term costs, the long-term value of learning and employee retention is far greater.

For tools and information about assessing your organization’s safety leadership and culture, visit nbaa.org/safety.