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Just Culture: SMS and You

October 11, 2017  By Walter Heneghan

There are many key components of a fully functional Safety Management System (SMS), both for the individual players in the system and its institutional masters.

When it comes to creating a sound safety culture There are many key components of a fully functional Safety Management System (SMS)

The four pillars of safety that encompass the 14 distinct elements, (as detailed in the ICAO SMS structure), include: a requirement for a safety policy and objectives, adequate safety risk management, safety assurance and safety promotion. The question about how we adequately manage risk and meet assurance criteria really are the keystones to a vibrant and evolving SMS and the entire system is completely informed by the company’s culture.

As SMS has advanced in Canada, so has the overriding culture of safety within our industry. There is much more awareness of what I have previously referred to as “active risk management” – the daily or regular review of one’s activities before they begin, and the constant and regular awareness that conscious thought is required to be risk-aware.

Risk-awareness is a precursor to risk management. James Reason, Patrick Hudson, and Sidney Dekker have all laid the foundations for us in understanding one’s safety culture and for affecting a strong safety presence. Prof. Reason’s elements of a safety culture include these components:  an informed culture, a reporting culture, a learning culture, a just culture and a flexible culture. Further, he expanded in the Journal of Injury Control and Safety Promotion that: “. . . a safe culture is an informed culture, one that knows continually where the ‘edge’ is without necessarily having to fall over it. The ‘edge’ lies between relative safety and unacceptable danger . . . navigating this area requires considerable skill on the part of system managers and operators. Since such individuals come and go, however, only a safe culture can provide any degree of lasting protection.”

For a simpler expression of safety culture, we can use what remains one of my favourite definitions: “Safety culture is the way we do things around here.” This rather simple definition captures the essence of “culture” in the context of each individual company’s operations, but it does not mean that the defined culture is actually a safe culture.


It may be that the prevailing way of doing things is archaic, backward, unsafe, unjust, blame-filled and wrong. One hopes this is not the case – and being informed about safe practices is a positive step forward in avoiding a toxic safety culture.

 Furthermore, with an “informed culture,” there is an implication that there is more than just a wishful desire to actually be informed. This occurs only after risk assessment and risk management processes are put in place and only if the company management deems this as a desirable outcome.

As Patrick Hudson has said of the notion of an informed culture, “Managers know what is really going on and [the] workforce is willing to report their own errors and near misses.” This takes real work and can only exist if other key elements of a safety management system such as good reporting and risk awareness/assessments are developed and used.

How to Get There
Reporting systems are critical. There are many types of systems available in this day and age – and it really doesn’t matter what system you use in your organization – only that there must be a system in place that is easy to access, (can be anonymous) and generates an information flow in both directions.

Few companies today use paper-based systems but if that is what you have or need, then use it. Online reporting is “de-rigeur” and the ubiquitous smart phone/tablet makes this step a virtual no-brainer. Get your line and maintenance staff to develop a habit of reporting what is happening within your operation and your managers will be informed and able to respond appropriately.

Appropriate responses are very important. Knee-jerk reactions to reported anomalies will kill your reporting channels and any trust that has been created between management and staff. Encourage reporting. Respond accordingly.  Provide feedback. These three elements are key to sustaining a reporting culture and developing an informed management team.  

Laying Down the Parameters
An established reporting culture aids in developing an informed culture. How management addresses these reports is the crux of a just culture. Effective safety management demands a move away from “blame culture” past a “no blame” culture into a “just culture.”

Just culture can be a tricky thing to achieve and to properly understand it, one needs some background. It is not my intention to recreate a treatise on the complete just culture paradigm – Hudson, Dekker, Reason, Marx et. al. have written considerably on those fronts, but a recap is important for context.

The old way of thinking regarding the management of errors in the workplace had a simple but largely punitive structure: rules and procedures are there for a purpose and company staff are expected to know them. There are clear expectations regarding these published procedures and non-compliant behaviour is considered to be a deliberate failure of an individual. These failures cannot be tolerated and non-compliance is best managed by making people aware of the personal consequences, from written warnings to dismissal.

 This view assumes that all the published procedures are optimal but some studies suggest otherwise. But there is substantial anecdotal evidence that much rule breaking is a result of a desire on the part of employees to “get the job done” or “to do the right thing.”

Often, this rule breaking is a result of a process or procedure being created that does not actually represent the daily norm for a given activity. It can also be a result of employees assuming the client wants something done a certain way; or a task that is completed for the “benefit of the customer.”

How then should rule breaking be treated? Reason, Hudson, Wiegmann and Shappell have written extensively about errors (slips, lapses and mistakes), violations and intentional and non-intentional acts. Slips are usually benign, not so dangerous on their own as one usually gets a reminder that you are doing the wrong thing.

Lapses are more dangerous and harder to contain – like forgetting to buy milk. Mistakes are even more dangerous as you intend to do one thing, but actually do something else. Violations are deliberate and break a fundamental assumption of a SMS: procedures will be followed.

Clearly, employees are acting in good faith, albeit in a non-compliant manner. A blame culture paradigm that is unflinching in dealing with these “bad actors” misses the point. The desire to inhabit a model that addresses these forms of non-compliance with reason was widespread and the concept of just culture was born.

Just culture models help navigate the world of error versus violation and provide aid in managing appropriate responses. A number of solutions such as Prof. Hudson’s “Hearts and Minds,” David Marx’ patient safety paradigm or the algorithms developed by Baines Simmons provide strong just culture processes.

Many larger companies have deployed these models with success since these models, when properly taught and implemented, can greatly enhance the effectiveness of a SMS, and will move the organization closer to a true safety culture. Top managers require an unwavering commitment to sustaining just culture principles and employees need to believe in that commitment.

Building a Stronger Paradigm
The just culture models discussed so far are really intended to be tools that assist management to address errors, mistakes and acts of individual actors and their behaviour. They require a strong and dedicated commitment on the part of management and need to be applied deliberately and in a consistent manner.

But what about the companies themselves? Can just culture principles apply to the larger organization as an “actor” in safety management or is the blame/liability model necessarily prevalent? Are the culpability constraints more appropriate to “bad actor” companies?

There is growing movement within hospitals, for example, to attempt to find the balance between the liability/culpability model and the development of a learning, generative just culture. Personal accountability balanced with legal liability with an eye to just improving the medical process is the ultimate goal in these medical organizations but it is a difficult path.    

The goal of these models is improvement but they do not immunize individuals from non-compliant or deviant behaviour. What standard then is needed for organizations?  Surely, when organizations act in a wilful manner, disregard best practices, ignore published procedures or plainly behave in a manner that is unsafe, then it is reasonable to expect a full accounting for their decisions. Can a “good faith” argument apply?

The substitution test, as first delineated by Prof. Reason, posits that if others, substituted into the same scenario and confronted with the same human factors liabilities, contributing and causal factors, would, or might, have committed the same errors, then the professional actions of supervisors and credentials committees should be moderated.

In such circumstances it is apparent that problems within the systems are at least in part, substantially responsible for the errors. The factors cumulatively resulting in errors become understandable and thus steps can be put in place to ameliorate or modulate circumstances contributing to error.

If an organization acts in a manner that is clearly outside the norms for safe or standard operations or outside of what other companies in the same or similar fields have done, then isn’t this a failure of the substitution test? And when this failure occurs, what steps should be taken? Just culture principles are designed for individuals and cannot be applied to organizations.

When organizations show intent and then carry out their intended actions, we are left with determining if those actions were deliberate (a violation) or a mistake. How does one determine the violation? Cleary, violations against legal codes and regulations or laws can be pretty straightforward and remedies are available via a legal or administrative process.

Aviation regulations and labour codes are in place for good reason. They protect employees and the traveling public and are intended to ensure minimum safety standards are in place. Compliance with these regulations and standards fulfills the company’s duty of care.

The next question to be posed is the notion of “the reasonable man” – in that, what would a reasonable person conclude that the observed behaviour was a reasonable action given the circumstances? These are important questions to be answered when evaluating how to respond to organizational misbehaviour. Many organizations develop a unique personality, and when this personality is one where advice is ignored or best practices are cast aside, then that organization and its component actors need to be held to account. Can there be violations against “best practices?” One potential remedy might involve bodies with which companies have been accredited. These organizations could then take steps to sanction where appropriate to correct the shortcomings of the offending company.

Accountability is key. Companies that successfully engage in just culture processes in the face of human error related events show themselves willing to be transparent in the name of safety. These paradigms allow for a full review of the context or envelope surrounding a safety event and provide strong guidance to the organization to ensure an adequate and just response that serves the needs of the all the players in the process.

Don Norman, the author of The Design of Everyday Things provides a most succinct summary of why just culture may be the way forward. “People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”


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