Page 36 - World Airnews Magazine February 2020 Edition
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HUMAN HUMAN
FACTORS FACTORS
WHAT IS A JUST CULTURE? portunity to learn from their mistakes and leads to potential problems
Such a ‘blame and shame’ culture does not afford individuals the op-
being hidden.
In certain organisations, one can find that perception is driven by
A buzzword in aviation human factors circles, ‘Group Think’. The sad fact is that when lost in a crowd, average indi-
By Eon de Vos viduals can become exceptionally virtuous or deadly. Their behaviour
depends on how they believe they are expected to act.
“It is never redundant to stress that human behaviour does not take
place in a vacuum. Corporate culture is an organisational mandate
which conditions decision making, and humans exhibit the kinds of
behaviours the organisation fosters and which they therefore assume
the organisation expects from them”. (Merrit et al)
4
Any negative event elicits speculation about where the blame lies.
We still look for a scapegoat when confronted with an accident or
incident with no immediately apparent solution as to its cause.
To quote Kenneth Quinn:
The best way to honour victims of a tragedy is to make sure we
obtain all relevant information that might prevent future acci-
dents. If individuals are not helpful to investigators out of fear of
being prosecuted and sent to jail, investigators may never discover
the truth. Stated differently, we found that the risk that the threat
of criminal prosecution places on the future safety of air travel
greatly outweighs any societal benefit in satisfying the inherent
human desire for revenge or punishment in the wake of a terrible
loss. (My emphasis).
5
This ‘inherent human desire for revenge or punishment’ leads to the
downfall of our envisaged Just Culture.
As draconian as lethal retribution might seem; science has shown
that the human brain can take pleasure in certain kinds of revenge.
Magnetic resonance imaging (MRI) scans have revealed that thinking
about revenge activates the reward centre - where the feel-good neu-
rotransmitter dopamine is lodged- in much the same way that sweet
foods or even drugs can. 6
It appears that our fascination with finding a scapegoat and assign-
ing blame is rooted in our genes!
Our problem is further exacerbated by the phenomenon of social
media and citizen journalism. Suffice to say that if bots and trolls could
influence presidential elections, social media could well influence pub-
lic perceptions of aviation incidents and accidents. Boeing and the FAA
recently learnt this lesson the hard way, with their delayed response
to the Max disasters, and we only have to peruse the many internet
aviation forums to see how the scapegoat is still sought for each and
tween acceptable and unacceptable behaviour lies. every situation.
3
Dekker (2009) explains that the issue of who draws such a line is Should those in positions of power believe that their duty entails
ccording to ICAO: “A healthy Just Culture plays a vital critical, given the relative nature of perceptions of justice and fair- the relentless pursuit of any misdemeanours, punishing those who (in
Arole in a successful safety culture by encouraging em- ness. This relativism makes it difficult to define justice and fairness, their opinion) are to blame - then we very quickly end up with a blame
ployees to report safety incidents and hazardous conditions. This and consequently, just culture. and punish culture, one which I propose was and is currently still
information enables the proactive identification of safety-related For our aviation purposes Just Culture can be considered a realis- active in our aviation environment.
problems and allows for the identification of safety trends. A criti- tic and effective compromise between the extremes of blame and The answer is to ‘walk the Just Culture talk’ and for companies and
cal part of Just Culture is also the responsibility to be consistently no-blame. regulators to react appropriately to pilots’ and employees’ reports.
intolerant of wilful misconduct or reckless behaviour. Adopting a IS THE REQUIREMENT OF A CLEARLY DEFINED LINE BETWEEN This would allow pilots and crew to feel empowered to report issues
clearly defined Just Culture policy and programme will benefit the ACCEPTABLE AND UNACCEPTABLE BEHAVIOUR SATISFIED IN and then we may eventually achieve that elusive Just Culture. Q
safety management of each aviation organization.” 1 CONTEMPORARY AVIATION? ARE WE ACHIEVING THE RE-
But whether it could actually be achieved is debatable. QUIREMENTS OF TRUST, LEARNING AND ACCOUNTABILITY?
Feedback by pilots from a variety of airlines, as reported during REFERENCES
‘Justice’ and ‘Fair Play’ are human constructs - abstract concepts CRM courses presented by the author, indicates a clear perception 1. https://www.icao.int/Meetings/a39/Documents/WP/wp_193_en.pdf ICAO
created through human imagination. For example, Plato, Aristotle, among air crew that Just Culture is more myth than reality. Working Paper Improving Just Culture
John Locke and John Rawls - all from different centuries, present When pilots refrain from reporting technical or procedural snags, 2. Dekker, S.W.A., 2009. Just culture: Who gets to draw the line? Cogn. Tech-
divergent philosophical discussions on the nature of ‘Justice’. because they fear being victimised (even fired), that is when we nol. Work 11, 177–185. https://doi.org/10.1007/s10111-008-0110-7
Justice is thus very much in the eye of the beholder – open to find serious problems are swept under the carpet - with potentially 3. James Reason (1998) Achieving a safe culture: Theory and practice, Work
& Stress: An International Journal of Work, Health & Organisations, 12:3,
manipulation and misinterpretation. disastrous results. 293-306, DOI:10.1080/02678379808256868
In our frequent CRM discussions with aircrew from many differ-
HOW TO DEFINE JUST CULTURE IN AVIATION? ent airlines, fear of retribution often surfaces as the reason for in- 4. Helmreich, Robert & Merritt, Ashleigh & Wilhelm, John. Error and resource
management across organizational, professional, and national cultures.
According to Dekker (2009), Just Culture is a culture of trust, learning hibited reporting – note that this perception often does not reflect 5. Quinn, K.P., 2007. Battling Accident Criminalization. AeroSafety world 2,
and accountability. 2 the true situation, but perceptions drive people’s reality. Thus, we 11–14.
Reason (1998) states that a prerequisite for just culture is find that many situations with potentially lethal consequences are 6. McCullough, M., 2008. Beyond revenge: The evolution of the forgiveness
instinct, 1st edition. ed. Jossey-Bass.
a clear awareness among all personnel of where the line be- simply not reported.
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