Why a just Culture?

Many of the most wonderful things we enjoy today are the result of endless trial and error. Take flight for example. After the Wright brothers successfully managed the first powered flight on December 17, 1903, many decades of trial and error, of success and disaster followed to evolve their first planes and have led to air travel with jet speed in comfortable pressurized cabins and all for the price of a pair of jeans. Similar stories can be told about surgical procedures and chemical plants. Safely and efficiently, they generate, transport, cure or produce to fulfil society’s primary needs.

These industries are run by people. Whether they are administrative support,  chemical specialist, process engineer, doctor, nurse, pilot or air traffic controller, they are the specialists that form the heart of our services. It is them that provide the everyday safety that we have come to take for granted. They form part of an essential chain that, together, forms the risk barriers that the industry has in place for protection against hazards.

Although carefully selected, trained and kept competent in what they do for us, they are humans and inevitably, humans will make errors. And if they happen to be the final risk barrier (see the Swiss Cheese model), serious mishaps may occur.

A significant contributor to the achieved safety level, is the consistent learning from mishaps and safety events to prevent recurrences. Frequently this leads to conclusions about people that have made errors of operational, technical or organisational nature. When the stakes are high, a natural response to faults and errors may be to look for the culprit and to punish them for putting our lives at risk. The fear for punishment that this brings about may in itself become a major reason why systematic problems are left uncovered and uncorrected. If we want these people to perform these jobs for us, we must find a way to deal fairly and justly with the inevitable human errors.

A Just and Fair Culture is where people are clear about what the right and wrong behavior is. They know when they cross the line and what the consequences could be. As professionals they have drawn that line themselves. 


Based upon the literature and our own observations in practical circumstances human behavior can generally be classified into four different categories.

   There are actions that clearly need rewarding! For the person, for the team, for the supervisor, or for the manager if the team performs consistently. This classification is true when people act above and beyond the call of duty. They are no longer just "operators" with common sense and good professional attitude, but also interpret the system as a whole and are aware of consequences of any changes in it. Particularly they can see further than just operations and demonstrate awareness of the value chain upstream, such as work preparation or management.

 The majority of the actions of your workforce obviously falls into the category "by the book". As it should. It is what professionals do all the time. They work by the book, because they have been trained to do so and because their experience tells them also what to do and what not. When they spot difficulties coming, they intervene as would be expected from a professional. Their experience is very necessary to draft the procedures as they, and thus you, would want them.

  Human error is just that: people are people and will forget to take an exit on a road, will forget to bring something to the office, despite the fact they had laid it ready for the next morning to be taken. Also, it could be that people apply a certain procedure to a task in error, whilst believing this was the right thing to do, such as pressing a button on a computer, expecting a certain result, however the computer did something else and it ends up as a surprise. This is where most of your unintentional safety events will classify (hopefully). People are humans, humans make mistakes. It's that simple. You will have to find a way to deal with the inevitable outcomes WITHOUT prejudging the action or behavior of the person involved. Obviously, it is not a free ride forever. People making repetitve mistakes clearly need attention!  

  Violations are all situations where rules have not been applied or have been transgressed, whatever the reason. It could be benign, because there was no other way to get the work completed, or, on the other end of the scale, it could be complete reckless behavior, such as exceeding a maximum speed limit on a highway by a ridiculous amount, ignoring all warnings and precautions. It is usually the more difficult part of Just Culture, but very necessary. Never have we seen a company where the rules and procedures are perfect. Expect "violations" (the term is perhaps a bit too suggestive and heavy) to happen. Investigate WHY they were violated: fat chance that there was a perfectly good reason for it. Then go change those rules! Unfortunately, this class of situations do include intentional violations of the wrong sort. People optimizing their own situation or just plain reckless behavior. Do - Not - Tolerate. Necessary part of Just Culture!


To achieve a Just Culture, it is extremely important to recognize the intention to act, and the actual behavior of a person. As strange as this may sound, you should never mix the outcome of a safety event (succes OR failure!) into the equation.

If you want the people in your company to act as best as they can, they have to feel sure that whatever they do, they will be dealt with fairly and justly. If an unfortunate outcome is part of the judgment by superiors, your workforce is guaranteed to act on their fears for unjust treatment, rather than speaking up on slips, lapses, errors, mistakes and the like. That is not just, and hence not safe.