A Just Culture and Why it’s Important to Your Business

By Mike Schwartz, MS, ATP, A&P 

 

Many of us that work at airports have seen aircraft that have experienced some hangar 

rash.   If it happens to a light single engine aircraft, the damage might not be too 

expensive to repair, but if it happens to a private jet, well the costs are significantly 

higher, not to mention the loss of revenue from not being available for dispatch.  How 

did your organization handle this situation?  

 

Aviation has a reputation of being intolerant of error.  It is not uncommon to work in an 

environment where everyone knew that if you made a mistake, you would be fired.  This 

is known as “holding the person accountable for their actions.”  In fact when you hear 

“hold the person accountable” you can usually substitute “termination for making a 

mistake.”   

 

Instead of being reactive and punitive, what if we took a step back and analyzed what 

caused the mistake to occur in the first place. We should ask questions that would lead 

to the primary cause of the event.  Some questions we should be asking are:

  • What led to the incident? What can we be doing better?
  • Did management have enough personnel on shift to safely perform the task?  
  • What about training?  Did it stop at “Don’t scratch a plane or you will be terminated?”  Yes, I have actually heard that said in training.  

A “just culture” is one where employees are given the benefit of the doubt.  

Management assumes positive intent on the part of the employee.  Procedures are 

routinely monitored and evaluated to ensure that they are effective and employees are 

provided the correct tools to do their jobs.  Inefficient procedures are improved upon 

and unsafe practices are removed from use. 

 

While no business can afford to pay claims as a result of accidents, can it afford to 

replace skilled employees that have made a mistake? Perhaps a better question to ask 

is, “Can the company afford to replace an employee that made a mistake because they 

were set up for failure?”  I am willing to bet that the best employee you will have is the 

one that made a mistake and that you provided remedial training. I am sure they won’t 

make the same mistake in the future.  As an example, if a pilot gets task saturated 

during a complicated instrument approach and forgets to put the gear down and lands 

the aircraft on the belly, do you think they will ever do that again?  I believe they will 

NEVER want to hear the sound of metal on asphalt and will do everything humanly 

possible to never get in that situation again.

 

Now a just culture does not mean that management must turn a blind eye to everything 

that employees do. A just culture also requires the organization to provide employees a 

list of unacceptable behaviors.  Violations of these behaviors should be dealt with swiftly 

and appropriately.  

 

  James Reason, in his 1997 book Managing the Risks of Organizational Accidents 

provides a decision tree that can be utilized to determine the culpability of unsafe acts.

This flow chart provides a good process for management to follow when deciding 

appropriate actions to take when an incident occurs.  

 

When investigating an accident or incident, it is important to keep the focus of the 

investigation on the system or processes in place so that the focus remains on objective 

facts that can be used to identify system deficiencies.  This information, when properly 

utilized can help prevent future recurrences and improve system reliability.  The key 

here is to focus on “why the event happened”, not on “who did it.”  In a just culture, it is 

important to distinguish between error and intentional or willful non-compliant actions.

 

When establishing a just culture in your organization, it is also important to have an 

environment where employees feel comfortable reporting safety or operational 

information to management.  Front line employees are usually in the best position to 

identify hazards, issues and processes that are unsafe or inadequate.  Policies that 

encourage employee reporting can result in recommendations and suggestions by 

those best suited to carry them out. 

 

When you focus on correcting substandard system processes and not on deficient 

employee performance, you will improve operations throughout your organization.  And 

everyone benefits from this.

 

NOTE from EasyFBO:  This is the first of a series of posts intended to be beneficial to your FBO business.  Thanks to Mike Schwartz for kicking it off!