Debrief: A Just Culture

A Just Culture

by Arnaud Delmas. This article is one of many excellent articles published by Jean Gabriel Charrier and his team on the French Web site. It was translated from its original version and is reproduced with permission.

From a “punitive culture” to a “just culture”
Since ancient times, people have always been held responsible for their actions, even unintentional errors. Is it the notion of “an eye for an eye, a tooth for a tooth” that holds in check the desire for justice—or vengeance—felt by victims’ families and the public? As human beings, we believe that the person responsible is also the person to blame.

This interpretation of justice or the “punitive culture” has not evolved very much, except regarding the types of punishment, which are far less barbaric! Under the French penal code, not only negligence or carelessness, but also clumsiness or lack of attention are considered just cause to impose a heavy penalty, such as death or serious injury, on the person responsible for an accident.

Aviation is one of the high-risk activities in which complex systems are in play, and safety is a determining factor. This “punitive culture” is increasingly perceived by the operators of these systems as unjust and ineffective:

  • unjust, because a mishap and the deliberate violation of rules are condemned in equal measure;
  • ineffective, because contrary to the “one rotten apple theory”, we all, without exception, make mistakes. It is unrealistic to claim that human error can be eradicated!

In fact, a “punitive culture” does not differentiate between the mistake that constitutes a deliberate infringement of a rule and the error that is unintentional. Error can be seen as an unintentional infringement.

In our increasingly litigious society, where we are all trying—quite rightly—to protect ourselves, the “punitive culture” has two adverse effects on aviation:

  • refusal to take risks, which is arguably an application of the “precautionary principle”;
  • failure to divulge errors so as to “preserve the right of defence”.

And yet, to achieve progress in the field of safety, it is much more effective to analyze the errors made by those who were lucky enough to escape and who are willing to talk about it, rather than to try to get the wrecks and the witnesses to give up their secrets when those involved in the tragedy are dead.

Serious accidents are only the tip of an iceberg of accidents, incidents and events that are significant for flight safety. By reducing the number of these events, it is hoped that the likelihood of a serious accident can also be reduced. To achieve this reduction, it is first necessary to acquire a good understanding of the causes of each event.

Flight safety is based, therefore, on transparency and on the sharing of information. Indeed, to be effective, all feedback systems rely on each person’s willingness to provide essential safety information, which often means being prepared to report one’s own mistakes and errors. It is essential to establish a “just culture” in order to create a climate of trust that encourages and facilitates communication and the sharing of information.

A “just culture”
The concept of a “just culture” is based on a non-punitive attitude toward human error. Voluntary transgression on the other hand must be punished.

Professor James Reason defines a just culture as “an atmosphere of trust in which those who provide essential safety-related information are encouraged and even rewarded, but in which people are clear about where the line is drawn between acceptable and unacceptable behaviour.”

European Union states and organizations have proposed the following definition: “A culture in which front-line players are not punished for actions, omissions or decisions proportional to their experience and training, but also a culture in which serious negligence, deliberate violation and destructive acts are not tolerated.”

France’s Civil Aviation Code (s. L 722-3) states that: “No administrative, disciplinary or professional sanction can be imposed on persons who have reported a civil aviation accident or incident or an event..., under the conditions stated in section L. 722-2, whether or not those persons were involved in the accident, incident or event, unless those persons were themselves guilty of a deliberate or repeated breach of the safety regulations.” [Translation]

In light aviation, this protection is provided to pilots who report an event to the Recueil d’Événements Confidentiels (REC) [confidential reporting system] created by France’s Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) [civil aviation accident investigation agency]. The report is not anonymous, but it is confidential; those involved are not identified in the reports of the REC.

The four basic principles of the Canadian Air Force’s Flight Safety (FS) Program provide another interesting example[1]:

  • The main focus of the FS Program is on the prevention of occurrences. Although cause factors are assigned to occurrences, this is only done to assist in the development of effective preventive measures (PMs).
  • Personnel involved in conducting and supporting flying operations are expected to freely and openly report all FS occurrences and FS concerns.
  • In order to determine the cause of occurrences so that appropriate and effective PMs can be developed and implemented, personnel involved in conducting and supporting flying operations are expected to voluntarily acknowledge their own errors and omissions.
  • In order to facilitate free and open reporting and voluntary acknowledgement of errors and omissions, the FS Program does not assign blame. Personnel involved in a FS occurrence are de-identified in the final reports and the reports themselves cannot be used for legal, administrative, disciplinary or other proceedings.

Establishing a “just culture” in a flying club
In order to promote trust, it is essential that reported occurrences are dealt with in the strictest confidence. In a small organization like a flying club, this is the responsibility of the “flight safety representative”, as distinct from the chief pilot.

In this environment, a “just culture” means:

  • In cases of error or involuntary infringement, no sanction is imposed.
  • All events involving flight safety must be reported to the flight safety representative.
  • Reported incidents are treated as confidential (no public confession!) and feedback is used in a depersonalized form.
  • Sanction is imposed in cases of deliberate or repeated breach of safety regulations, or of failure to report any obviously significant incident.
  • Since all those involved are called upon to acknowledge their errors and omissions, a request for retraining is not seen as a sanction, but as a normal part of the process.

Often, these aspects of a “just culture” are already in place, but they should be set down in specific internal regulations that everyone is aware of and that are applied.  

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