The Power of Just Culture: Killing the Blame Game

In many companies across the globe, if something goes wrong, the go-to response is to start finger pointing and finding someone to blame. In aviation though, we sure like to think we’re better than that, but are we really? As the aviation industry has developed over the years, we’ve learnt that the old school blame approach leads to a toxic environment. Blame also takes away the opportunity to learn from mistakes. A just culture aims to improve this. So what exactly is the power of a just culture, how can we contribute to it, and what are the dangers of a blame culture?

In this article, we will explore some shocking experiences of blame culture and the ins and outs of just culture. We’ll also look at just culture’s potential benefits for organisations, and all of us who work in aviation. How can we implement and support a culture where mistakes can be openly discussed? All of this doesn’t just apply to aviation, it’s also very relevant in medicine and any other industry where safety is crucial.

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What is Just Culture?

Just culture is the opposite of a blame culture. The UK CAA defines it as:

“A Culture that promotes continuous learning from previous mistakes and to encourage pilots to openly and freely share essential safety related information.”

We all know we will inevitably screw up at some point in our career. Pilots are human, and humans aren’t perfect. This isn’t anything to be ashamed of. We need to find ways to accept this and make sure it is mitigated for, in the best way possible! Blame and shame don’t usually benefit the overall system in the long run, in fact it’s proven to hurt it!

Everyone should feel able to raise their hand and say “I screwed up, how can I and others around me learn from this?”. If we don’t have a culture that empowers people to say this, people will simply stop reporting errors and hide mistakes. Without error reporting, there is no learning, without learning, there are no improvements to overall safety. All pretty logical so far, right?

This ‘safety loop’ is shown below. As you can see, just culture is one of the 5 subcultures that work together to create a safety culture:

A just culture recognises that errors are inevitable in complex systems, and that blame is not always useful or fair. Instead, it encourages open communication, learning from mistakes, and supporting people to talk about their mistakes.

When we look at the safety culture pyramid (Patankar, 2010), we can see ‘just’ is again a key part. The pyramid shows how safety culture comes from organisational culture. Basically, the shared values and beliefs of a company, with ‘justness’ coming from our behaviour:

But what about negligence you ask? Good question! Despite what many of us think, just culture doesn’t mean ‘don’t ever hold anyone accountable for anything’. That would also be a recipe for disaster, especially in an industry where safety is the building block of the operation.

There are three levels of behaviour that our actions can be identified as (Reason 1997). First we have unsafe acts, which are mistakes that anyone of us could make. Second is negligent errors, and third malevolent damage or substance abuse for recreation, which especially in the aviation industry is unacceptable:

Accountability needs to be taken for actions that are intentional, reckless, or blatantly ignore policies and procedures. The tricky thing is that this can be very fine line. How do we define what counts as negligence, and what counts as a mistake?

We need some structure to how we look at mistakes vs negligence. Have a look at this flowchart based on the work of Reason (1997). This will hopefully help you gain insight in how to judge whether something is system-induced, a simple mistake, or gross negligence. Start at the top left, and then work your way across the flowchart to see what sort of action you are talking about:

Now it can get tricky at the “were procedures knowingly violated?” and “could a similar person have made the same error?”. These are both very subjective and not so black and white. This is usually where debates and arguments start within companies.

Despite that, this framework provides a fair structure to evaluate tricky situations!

Real Life Examples of Blame Culture in Aviation

Over the years, there have been numerous instances where companies haven’t protected pilots when errors have been reported. This isn’t just limited to how pilots get treated of course, but all people in the company. But how do you know if you’re part of a blame culture? Just ask yourself how comfortable you feel reporting something that you’ve missed, or carried out in the wrong way.

There are still MANY companies that actively encourage a blame culture. In a confidential survey, we asked pilots in our network about the most shocking experiences that they have had because of a blame culture.

Locations, names, companies and flight details have been taken out to protect those who were willing to share their experiences.

1) A pilot was asked to complete a ‘quick’ ground run on an aircraft post-maintenance. During maintenance, the engine oil system was fully drained. Engineering had forgotten to refill the oil, and the pilot started the aircraft not having checked the oil level properly. This caused damage to the engine.

The pilot in question took the brunt of it, his reputation within the company was tainted, and the company pushed him aside. This even resulted in him struggling to find another job.

2) A flight instructor was starting up an aircraft with his student. During the part where the throttle needs to increase, the student rolled on too much throttle (this was an aircraft with a manual throttle). This caused the rotorhead to overspeed. The company decided to charge the flight instructor money to cover the excess of the insurance costs.

3) A company incorporated the amount of ASR’s per pilot as part of their assessment matrix for redundancies. As soon as pilots knew about this, culture shifted to “write the least amount of ASR’s / don’t report errors’’. This is a very short-sighted way of running a safety-focussed operation.

4) Two pilots working for a large airline were getting the aircraft ready to depart at a major airport. The first officer noticed a caption on the warning panel and informed the captain. They both discussed the source and consulted the MEL, which stated that a maintenance action was required.

This was actioned by the company (engineers were present). After a very short period, the engineers returned to the cockpit saying the aircraft was good to go and fully signed off. Both pilots were very confused, as this maintenance action should’ve taken much longer. They called HQ, who called the maintenance organisation on site.

It turned out that the manager of the lead engineer instructed him directly to just sign it off, without fixing it properly. When the lead engineer spoke up about this, he was fired, while the manager didn’t take any accountability and still works there.

5) A pilot working at a flight school was charged a large sum of money for accidentally breaking a chin bubble on a helicopter while on a positioning flight. The money charged was stated to be for the insurance excess, however the insurance was never claimed.

6) A company told pilots during an annual meeting that whoever caused damage to the aircraft landing gear a few weeks before, will be entering a process of disciplinary action. Certainly one way to make sure whoever made the mistake will never come forward!

We didn’t want to make the list too long, but it definitely illustrates that there are still companies that actively punish pilots for mistakes. This only makes it more difficult to get pilots to admit mistakes, and report errors. Example number 6 is particularly ironic, as the company seems oblivious to the fact that by talking in that manner you’re introducing more barriers for a more honest reporting culture. It really isn’t rocket science…

The Dangers of a Blame Culture

The opposite of a just culture is a blame culture. You can probably understand that if you were to criminalise aviation accidents, pilots would probably introduce more lies and cover up stories to make events not sound as bad as than they were.

But that doesn’t just happen with criminalising accidents. Finger-pointing cultures and punishments for accidentally doing something in the wrong way, can have detrimental effects on a safety culture. What are the top 5 dangers of blame culture? Let’s have a look:

1) Fear and mistrust: Would YOU report something if you KNEW punishment will follow after owning up to a mistake? Employees will trust everyone around them less, as they’ll try to make sure no one can report them either.

2) Cover-up culture: Employees may avoid admitting their mistakes and trying to learn from them. Instead, they may be tempted to cover up their errors or shift the blame onto others. This will eventually lead to a culture of dishonesty and evasion. Identifying and addressing problems across the system will then become harder. An absolute nightmare for any company to improve overall safety.

3) Lack of innovation: When the focus is on blaming individuals rather than solving problems, there is little room for creativity and innovation. Employees may be discouraged from taking risks or trying new approaches, for fear of being blamed if things go wrong. Simply suggesting something when you’ve identified a weak area within the organisation, could mean you lose your job! What a lovely environment right?

4) High pilot turnover: A blame culture can create a toxic work environment, and lead to high levels of stress and burnout for all involved! This can (and has for a lot of companies) lead to high pilot turnover. This may become very very costly and disruptive for the organisation, especially if you consider the costs and time it takes to train a pilot on a specific type nowadays.

5) Limited learning: Blaming individuals for mistakes that leads to punishment hinders the learning that needs to happen for an organisation to grow. How can employees learn from their mistakes if the first course of action is worrying about what is going to happen to them, and whether or not they still have a job?

Creating a Fair and Accountable Just Culture

So how do we contribute to a culture that facilitates reporting, learning, and honesty? Well there are a few steps involved. The first step is to change the way you look at errors within an organisation.

ASSUME errors will be made, people WILL screw up, and threats will CONTINUE to exist. To pretend that these don’t apply to you is insane.

So what else can we do? Here are the top 5 things companies should embody on the journey towards a Just Culture:

1) Establish clear expectations: You must establish clear expectations and guidelines for the kind of behaviour you’d like to see. You need to know what is expected of you, what behaviours are acceptable, and what will happen if you violate policies or procedures. These expectations should be communicated clearly and consistently throughout the organisation, and everyone should be on the same page!

2) Encourage reporting and learning: Companies should encourage employees to report errors, incidents, and near-misses, without fear of punishment or retaliation. The only way to do this is to actively state that punishment is NOT the way forward.

Reporting should be seen as an opportunity to learn from mistakes, identify systemic issues, and improve workflows, checklists, procedures etc.

3) Assess accountability: In a just culture, accountability is based on the nature and severity of the behaviour, not just the outcome. So if someone screws up, you need to ask yourself what that person went through and why they made the decisions they did. Don’t just look at the outcome and blame them for it.

Companies should assess the level of accountability for each incident. Specifically, whether the behaviour was intentional, reckless, or a result of a system or process failure. This assessment should be fair, consistent, and transparent. Have a look at the flowchart again to see if this makes sense.

4) Provide training and support: Make every employee ACTUALLY understand what it means to be part of a just culture. Does everyone know what a just culture is? Does everyone agree that reporting is important? Most importantly, does everyone involved FEEL like they can report errors without being punished or ridiculed?

The training should emphasise the importance of reporting errors and incidents, as well as how to identify and address systemic issues. This also includes providing support to employees who have experienced or reported incidents. To help them cope with any stress caused by it, and to make sure they continue to report errors.

5) Continuously improve: Aviation companies should continuously monitor and improve their internal cultures. There is always something that could be better. Whether it’s reviewing checklists, policies and procedures, or assessing the effectiveness of training and support programs. Collecting as much feedback from employees as possible to learn from how things are done right now, is also critical.

The Benefits of a Just Culture

So what are we getting out of it? Seems like a lot of effort so far, right? Well, the environment will improve in a LOT of ways. In particular:

1) Improved overall safety: Employees are encouraged to report errors and near-misses. This helps to identify potential safety hazards such as commercial pressure, and prevent accidents. This can lead to a safer work environment for employees and customers. If Dave from engineering can’t find his wrench after he worked on an engine bay the day before, you’d like him to report it right?

2) Increased accountability: A just culture promotes accountability for actions that are intentional, reckless, or blatantly disregard policies and procedures. This can lead to greater transparency and fairness in how incidents are addressed. In turn, this will reduce the likelihood of similar incidents occurring in the future.

It’s a misconception to think that “Oh we have a just culture, so I can’t be blamed for anything”. The opposite is true, accountability is still very important, but if it was a genuine mistake or omission, you shouldn’t get in trouble.

3) Higher employee morale: A just culture can create a more positive work environment, where employees feel supported, heard, and respected. This can lead to higher levels of job satisfaction, mental health, engagement, and retention. An environment where anyone who makes a mistake gets publicly blamed and shamed, would not last very long, unless you enjoy an ever increasingly intense recruiting process.

4) Better learning: Incidents and errors are seen as opportunities for learning and improvement, rather than opportunities for punishment. This can lead to a greater willingness to share information and insights, which will help identify systemic issues that could pose latent threats.

5) Stronger reputation: A just culture can enhance a company’s reputation as a responsible and ethical employer, committed to safety, fairness, and transparency. Pilots are constantly on the outlook for what companies have toxic work cultures, and are starting to avoid it like the plague. Especially once they get a little bit of experience under their belt. Most of us would rather make slightly less money for instance, if it means you don’t get shouted at!

Implementing a Just Culture

Implementing a just culture can be challenging, but here are some steps that organisations can take to get started:

Engage leadership: The first step in implementing a just culture is to gain commitment from the people at the top. Leaders need to understand the importance of a just culture and encourage others to do the same. If this box isn’t ticked, you can forget it ever happening within your company.

Define clear policies and procedures: Companies should develop clear policies and procedures that outline the principles of just culture and how they will be implemented. This should include guidelines for incident reporting, incident reviews, and making sure all pilots are aware of their responsibilities and discretion.

Communicate expectations: Once policies and procedures have been developed, they should be communicated clearly and consistently throughout the operation. This may involve training employees on the principles of just culture and the importance of reporting errors and incidents.

Build trust: Building trust is critical to the success of a just culture. Employees need to feel comfortable to report errors and incidents, and know that they will be treated fairly and without fear of punishment or retaliation. This may involve creating channels for anonymous reporting and ensuring that employees’ confidentiality is protected.

Conduct regular reviews: Operators should conduct regular reviews of incidents and near-misses to identify trends and areas for improvement. These reviews should be focused on learning and improvement, rather than blame and punishment.

Skybrary have outlined a handy set of commitments (which we’ve summarised below!), to help make just culture a reality. How much do you and your organisation follow these?

Conclusion

A just culture can bring significant benefits to airlines, operators, maintenance organisations, ATC and any other branch where safety is the building block of the operation. Benefits such as, improved safety, increased accountability, higher employee morale, more efficient learning, and a stronger reputation. Implementing a just culture requires a lot commitment, conversations, and effort from both management and pilots, but it has been proven to pay off in the long run!