KISS Flight Safety –
An atmosphere of trust where employees are encouraged (even rewarded) to provide important safety-related information, but where it is also clear where to draw the line between acceptable and unacceptable behaviour.
This is how James Reason, the mastermind in crew resource management and error analysis, describes the term Just Culture. So far so unclear… because what exactly does it mean for each and every one of us?
It is now well known that it is rarely the one mistake that leads to an accident. Rather, it is chains of errors that sometimes have fatal consequences. James Reason is also known for the Swiss cheese model, where he describes exactly that. When the holes in the cheese slices are on top of each other, fate takes its course. The ultimate goal must therefore be to move the slices so that the holes do not lie on top of each other. This can only be done by taking an honest look at the organisation, the systems, the procedures and, of course, all the people involved.
And honesty does not come about on its own and certainly not with the threat of punishment.
A living Just Culture enables us to deal with errors differently. Every individual is encouraged to report relevant information or even errors. This is why we have non-punitive reporting systems, for example. In a trusting atmosphere, the finger is NOT first pointed at the person who caused the problem, according to the motto “now we have our culprit, we can go back to sleep”.
No, the work only begins then, because it is explicitly investigated which systems, processes and circumstances contributed to this error being able to happen in the first place. So the individual slices of cheese are considered and the error chain is traced. In the best case, an adjustment of the system, of the environmental variables can be achieved afterwards, which will make the same error significantly more difficult in the future.
The basis of Just Culture is trust. Also trust that there are no penalties to be feared for pro-active reporting.
And yet, this is not the possibility of fool’s freedom. Anyone who deliberately flies too high and too fast, demonstrates through his actions that he is aware of the situation and continues anyway, only to touch down far after the halfway mark and the aircraft ends up going beyond the runway will have to reckon with appropriate measures even within a just culture.