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
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
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!