The document introduces the concept of a 'just culture' in aviation, emphasizing trust and open reporting of safety issues while defining unacceptable behaviors. It highlights that increased reporting is a key indicator of safety and enhances organizational effectiveness by clarifying performance expectations and consequences. The document stresses the importance of individual responsibility for safety and encourages proactive communication regarding potential hazards.

1. A Just Culture
MIKE SHAMA

2. AIM
To introduce the concept of what a Just Safety Culture is in aviation, with
application to all staff at Starlite Aviation

3. CONTENTS
• What is Just Culture
• Evolution of Safety Thinking
• Benefits of a Just Culture
• Defining the borders of Bad Behaviour
• Four Types of Unsafe Behaviour
• Determining The Culpability Of Unsafe Acts
• So where do you fit in at Starlite Aviation?

4. What is Just Culture
• An atmosphere of trust in which people are
encouraged (even rewarded) for providing
essential safety-related information, but in
which they are also clear about where the
line must be drawn between acceptable and
unacceptable behaviour.

6. Evolution of Safety Thinking
Technical Factors
Human Factors
Org Factors
1950s 1970s 1990s

7. Benefits of a Just Culture
• Increased Reporting
• A lack of reported events is not indicative of a safe operation, and
likewise, an increase in reported events is not indicative of a decrease
in safety. Event reporting illuminates potential safety concerns, and any
increase in such reporting should be seen as a healthy safety indicator.
• Trust Building
• Most violations are caused by a desire to please rather than willfulness.
This observation emphasizes the inherent nature of the majority of
safety violations: (i) that they are indeed inadvertent and (ii) that they
are intended to further the organization’s operational objectives.

8. Benefits of a Just Culture
• More Effective Safety and Operational Management
• Will enhance the organization’s effectiveness by defining job
performance expectations, establishing clear guidelines for the
consequences of deviance from procedures, and promoting the
continuous review of policies and procedures.

9. Defining the borders of Bad
Behaviour

10. • Human Error
• Inadvertent error
• Negligent Conduct
• Intentional , increases risk
• Reckless Conduct (gross negligence)
• Conscious disregard of substantial and unjustifiable risk
• Violations
• Knew the result and went ahead anyway
Four Types of Unsafe behaviours

11. A Decision Tree For Determining The
Culpability Of Unsafe Acts

12. Sidney Dekker on Just Culture
• Human Factors and System Safety, Leading Opinion
from Professor Sidney Dekker. Explains Just Culture;
why you need it, what it is, and how you get it.
• https://www.youtube.com/watch?v=t81sDiYjKUk

13. So where do you fit in at
Starlite Aviation?
• Importance of safety consciousness in all job roles
• Proactive approach to reporting
hazards/occurrences/incidents
• Sense of responsibility: an engineer can spot
something that saves a pilot’s life, a pilot can spot
something in maintenance that could save an
engineer’s life

14. SUMMARY
• Increased reporting improves safety for all, builds trust
between individuals and with Starlite (in both
directions), and makes us as an organisation more
effective and more efficient.
• Awareness of your behaviour and the potential for
errors.
• Just Culture is not a “no blame” culture. The individual
and the organisation are responsible for their actions
and policies.
• If you are ever unsure, or think something could be
unsafe, DO NOT BE QUIET. ASK.

15. QUESTIONS

16. A Just Culture
MIKE SHAMA