ALEA Safety First Program Newsletters
March 2008
Keith Johnson
Safety Program Manager
The Just Culture
I recently attended a
presentation by Dr. Patrick Hudson,
professor at Leiden University, during the
Canadian Helicopter Corporation Safety
Summit. Dr. Hudson addressed the issue of
Just Culture and Non-compliance.
The Just Culture provides
managers with a clear procedure for deciding
whether a rule violation is to be treated as
blame-free or whether some form of coaching
or discipline is appropriate. Just Culture
models are used in many organizations that
have high-risk operations. The logic behind
the model is that individuals who break the
rules should not be punished if it becomes
clear, following investigation, that there
was no attempt at sabotage or deliberate
creation of danger, nor if there were clear
system-induced causes. If, however, it is
apparent that the procedure was clear and
workable, then the individual should be
subject to some level of discipline.
The Substitution Test
should also be applied in order to ascertain
whether other individuals, with the same
level of experience, would be likely to
behave in the same way, even if the
violation had been induced by the system. If
there is clear evidence of shortcomings in
training, selection or experience, then the
failing should be regarded as a
system-induced error. One last assessment
examined whether the individual had a
history of violating procedures and only
those who were cleared by all tests could be
considered blame-free and not requiring
coaching or discipline. In the case of
system-induced violations or errors,
management/supervision has responsibility to
correct root causes of system issues.
Failures to follow
established rules and procedures form a
major cause of accidents in the aviation
industry. Attempts to confront the issue of
non-compliance to rules and procedures are
to be found in a wide variety of industries,
including aviation, health care, railways
and fire services. In a study by Boeing
Aircraft of aviation accidents between 1982
and 1991, compliance with procedures was
identified as the primary measure for
preventing accidents in commercial aviation
where well over 50 percent of all major
aviation accidents could have been prevented
if the pilots had followed procedures. The
UK Civil Aviation Authority has replicated
these finding more recently. In that study,
two of the most frequently identified
circumstantial or causal factors were found
to be incorrect/inadequate procedures and
deliberate non-adherence to procedures. At
first sight, the problem appears easy to
solve. All that is necessary to achieve a
high level of safety, whether personal
safety or related to process safety
management, is to ensure the highest level
of compliance to the rules and procedures
among the workforce. The best way to ensure
compliance is also seen as the setting of
clear expectations (standards).
Studying errors and
violations on the flight deck of commercial
airlines in the US, found that intentional
non-compliance constituted 54 percent of all
errors, with procedural errors being 29
percent (83 percent in total). But they also
found that in the cockpit environment, only
two percent of violations were rated as
consequential, while 23 percent of the
procedural errors increased the risk to the
flight. The most dangerous errors were those
of manual proficiency (stick and rudder
skills) as making such errors close to the
ground can be extremely unforgiving. Taken
together, these results suggest that
non-compliant behavior is very frequent and,
occasionally, lethal. Manual skills, while
very sensitive when there are no other
barriers in place, do not appear in many
accident reports just because the other
barriers are present and have been
effective, while non-compliance often
involves the removal of effective barriers
which make a serious outcome much more
likely. It is for these reasons that it is
important to manage non-compliance within
the workforce.
More information on the
topic can be found on the
ALEA website Safety
First section, in a paper by Dr. Hudson
titled: “Meeting Expectations – A New Model
for a Just and Safe Culture.” A Just Culture
model can be found in the
SMS Toolkit.
I must point out that this
is not an exact science. There has been
considerable research on Just Culture and
Non-compliance, and there are many different
models in use today.
Managers and supervisors
who wish to learn more about this topic
should attend the ALEA Annual Conference.
This topic will be covered in the
pre-conference Unit Managers’ Course and
in the Safety Management System track on
Friday during the main conference.
Have a question or
comment? Send it to me at:
safety@alea.org.
Keith
KEITH JOHNSON
ALEA Safety Program Manager
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