A Just Culture

MIKE SHAMA

AIM

To introduce the concept of what a Just Safety Culture is in aviation, with application to all staff at Starlite Aviation

CONTENTS

• What is Just Culture• Evolution of Safety Thinking• Benefits of a Just Culture• Defining the borders of Bad Behaviour• Four Types of Unsafe Behaviour• Determining The Culpability Of Unsafe Acts• So where do you fit in at Starlite Aviation?

What is Just Culture

• An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.

Evolution of Safety Thinking

Technical Factors

Human Factors

Org Factors

1950s 1970s 1990s

Benefits of a Just Culture

• Increased Reporting• A lack of reported events is not indicative of a safe operation, and

likewise, an increase in reported events is not indicative of a decrease in safety. Event reporting illuminates potential safety concerns, and any increase in such reporting should be seen as a healthy safety indicator.

• Trust Building• Most violations are caused by a desire to please rather than willfulness.

This observation emphasizes the inherent nature of the majority of safety violations: (i) that they are indeed inadvertent and (ii) that they are intended to further the organization’s operational objectives.

Benefits of a Just Culture

• More Effective Safety and Operational Management • Will enhance the organization’s effectiveness by defining job

performance expectations, establishing clear guidelines for the consequences of deviance from procedures, and promoting the continuous review of policies and procedures.

Defining the borders of Bad Behaviour

• Human Error• Inadvertent error

• Negligent Conduct• Intentional , increases risk

• Reckless Conduct (gross negligence)• Conscious disregard of substantial and unjustifiable risk

• Violations• Knew the result and went ahead anyway

Four Types of Unsafe behaviours

A Decision Tree For Determining The Culpability Of Unsafe Acts

Sidney Dekker on Just Culture

• Human Factors and System Safety, Leading Opinion from Professor Sidney Dekker. Explains Just Culture; why you need it, what it is, and how you get it.

• https://www.youtube.com/watch?v=t81sDiYjKUk

So where do you fit in at Starlite Aviation?

• Importance of safety consciousness in all job roles• Proactive approach to reporting

hazards/occurrences/incidents• Sense of responsibility: an engineer can spot

something that saves a pilot’s life, a pilot can spot something in maintenance that could save an engineer’s life

SUMMARY

• Increased reporting improves safety for all, builds trust between individuals and with Starlite (in both directions), and makes us as an organisation more effective and more efficient.

• Awareness of your behaviour and the potential for errors.• Just Culture is not a “no blame” culture. The individual and

the organisation are responsible for their actions and policies.• If you are ever unsure, or think something could be unsafe,

DO NOT BE QUIET. ASK.

QUESTIONS

A Just Culture

MIKE SHAMA