1. Just Culture George Monteiro Principal Airworthiness Surveyor

2. Just Culture in Aviation Safety: Key Topics
What is a just culture?
Impact of organisational culture on safety performance
Just, reporting, informed and learning cultures
Legislation, guidance and policies building trust
Assessing and measuring: determining culpability
Just Culture and safety improvement
Key topics as listed within course description (as advertised) – Each key topic become a module of the course.
What is a Just Culture?
The impact of organisational culture on safety performance
Just, reporting, informed and learning cultures as part of a developing safety culture – what does that mean to me?
Legislation, guidance and policies building trust
Assessing and measuring Just Culture: determining culpability
Just Culture and safety improvement
Its about the application of just culture rather than the term itself

3. Just Culture in Aviation Safety: Key Topics
What is a just culture?
Impact of organisational culture on safety performance
Just, reporting, informed and learning cultures
Legislation, guidance and policies building trust
Assessing and measuring: determining culpability
Just Culture and safety improvement
Key topics as listed within course description (as advertised) – Each key topic become a module of the course.
What is a Just Culture?
The impact of organisational culture on safety performance
Just, reporting, informed and learning cultures as part of a developing safety culture – what does that mean to me?
Legislation, guidance and policies building trust
Assessing and measuring Just Culture: determining culpability
Just Culture and safety improvement
Its about the application of just culture rather than the term itself

4. Not entirely a new idea Hurricane production 1940
Just Culture
Not entirely a new idea
A fault revealed voluntarily will be treated leniently but a fault concealed may lead to serious consequences for the workman, not to mention the pilot
Value to the people we oversee
Hurricane production 1940

5. How people feel – Psychological
What is a Just Culture? Safety Culture – Just Culture – Learning Culture?
Just Culture
Safety Culture
Learning Culture
In a just culture errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action
A learning culture means that an organisation is able to learn from its mistakes and make changes.  It will also ensure that people understand the SMS processes at a personal level
Safety Culture
Slide animated - points in order of animation:
Safety Culture
Not physics or math
It is a touchy feely subject.
Don’t be to precise on definitions – wasted effort
Learning Culture
Trying to get people behind the SMS is fundamental for SMS
Just Culture
Changes the no blame culture into the Just Culture. Allows people to admit “I screwed up”
Try and divorce the culture of the company to actually what happened.
How people feel – Psychological

6. Just Culture: Reasons to Report, or not…..
YES – Report it!
Don’t want aircraft to crash
I know I’m supposed to
Somebody saw me
It might happen again
I might get thanked
The system will support me
It’s the law
Easy to complete a report
NO – Hide it!
I might get fired
Nothing will change
I’ll look foolish
I might lose my Licence
Nobody noticed
It’s unimportant
It’s too difficult
If you are not sure report it.
Not easy to complete a report.
It is his job / responsibility
It’s what he’s paid to do.
Discuss each point, one at a time. (Each bullet animated one at a time)
Easy to complete - on the other hand they may not be if the system you use is not easy.
It is maybe worth considering that for some cultures reinforcing that its your duty to report it will help ie Japanese Culture
Its about creating the environment where they can and will report issues

7. What is a Just Culture? - Reminder
Making use of
the data
Cultivating an atmosphere where people have confidence to report safety concerns without fear of blame. Employees must know that confidentiality will be maintained and
that the information they submit will be acted
upon, otherwise they will decide that there is no benefit in their reporting.
Informed
Learning
Flexible
Just
Reporting
Organisation collects and analyses relevant data, and actively disseminates safety information.
Learning from the
mistakes
Safety Culture
Slide is animated
Dr James Reason has suggested that safety culture consists of five elements:
An informed culture
A reporting culture
A learning culture
A just culture
A flexible culture
Animated, in order:
In a just culture errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
A reporting culture means cultivating an atmosphere where people have confidence to report safety concerns without fear of blame.  Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting. 
In an informed culture the organization collects and analyses relevant data, and actively disseminates safety information.  
A learning culture means that an organization is able to learn from its mistakes and make changes.  It will also ensure that people understand the SMS processes at a personal level. 
A flexible culture is one where the organization and the people in it are capable of adapting effectively to changing demands.
Each one is relevant and do build on each other.
The type of reports that have gone through the system will show you how mature it is.
Organisation is able to learn from its mistakes and make changes.  It will also ensure that people understand the SMS processes at a personal level.
Errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
Organisation and the people in it are capable of adapting effectively to changing demands.

8. Just Culture Definition
Legislation, Guidance & Policies Building Trust: Legislation & Guidance
Guidance material CAP382 The Mandatory Occurrence Reporting Scheme further amplifies this protection of the reporter
A Statement by the CAA Chief Executive describes:
Assurance regarding prosecution
Confidentiality of reports
Possible action by employers
Action in respect of licences
Just culture
Just Culture Definition
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated
Definition originally came from 996 Air Traffic Regulations.
Just Culture definition will also appear in the new EASA regulations.
If you want to use a definition in your policy then this could be the one you use.
Deciding whether gross negligence was involved is not always straightforward. This will be discussed.
Making sure you have the procedures in place before something happens and you need to use them.
The challenge is how to interpret and apply the definition

9. Assessing & Measuring: James Reason – Culpability Model
Substitution Test – refer to next slide for further details
Question to peers: “Given the circumstances, is it possible that you could have made the same or a similar error”
If answer “yes” then blame inappropriate.
The best people can make the worst mistakes.
See Handout (Slide)
James Reason (Swiss cheese) Academic
Very general and can be used in any situation NOT just aviation.

10. Assessing & Measuring: Patrick Hudson – Just Culture Model
THE ORGANISATION
See Handout
Another academic one.
Work across the top and then you can work your way down.
This is a few years back and has since moved on.
The line in the sand (that is when you think about firing someone)

11. Assessing & Measuring: FAiR2TM System – Flowchart Analysis of Investigation Results
See Handout – 2 pages copy of slides (next slide does have the second part of the tool)
Instructor note: Baines Simmons maybe verbally mentioned – objective comments only (please do not provide any subjective view points)
The blue shaded boxes relate to the next slide
Tools Summary -
If there is one right way it would be in the regulation.
Up to the individual organisation to decide what works for them.
FAiR Version March 2015 © 2015 Baines Simmons Limited

12. Just Culture & Safety Improvement: Maintaining Focus
Wrong Screws
Window Blow-out
Contributing Factor
Contributing Factor
ERROR
EVENT
Fred makes an error by using short screws which results in a window blow-out event. – Fred’s error, incompetent? Get rid of Fred, fixed!
Fred doesn’t work in a vacuum, he is surrounded by contributing factors and it is these we need to focus on.
Our process should enable us to remove the emotion from the scenario to allow organisational learning and improvement.
If it hadn’t been Fred could it still have happened? If so the organisation needs to address the contributing factors, not sack Fred!
Contributing Factor
Contributing Factor

13. Just Culture & Safety Improvement: Effects of an ‘Unjust Culture’
Employees unlikely to report
Information source dries-up
Unsafe practices driven underground
Reputational damage – whistleblowing
Regulatory compliance failure
Unaware of organisation’s risks – no mitigation
Serious Incident or Accident?
Lets think of the flipside of not having a Just Culture.
Managers – Corporate manslaughter.

14. Why has Just Culture become so Important?
Safety Promotion
Safety Policy & Objectives
Safety Risk Management
Safety Assurance
Safety Culture
Remember
this?
The SMS Helicopter
Informed
Learning
Flexible
Just
Reporting
Safety Culture

15. Understanding of SMS: Practically, What is a SMS?
What do we not want to happen?
How do we prevent it happening?
Take appropriate action
How do we check it worked?
Managing your risks to prevent the ‘bad’ things happening
Accepting that things will go wrong but minimise the consequences
A means to identify and understand your safety risks
Slide animated.
Managing your risks to prevent bad things happening
Accepting that things will go wrong but minimise the consequences
A means to identify and understand your safety risks (know your unknowns)
(click to animate these bullets)
It is more than a safety manual
It is more than a database
It is more than a quality management system
It needs the right safety culture

16. Questions????