Guide to Understanding Just Culture

Thursday, May 30, 2024

Written by Senior Consultant, Peter Hibbert

Guide to Understanding Just Culture
Just Culture strikes a delicate balance between fostering open and honest reporting and holding individuals accountable for their actions. This balance is essential for enabling organisational learning and facilitating improvements. While aviation as been implementing Just Culture since the 1980s, its true essence might still be overlooked by many. Our Senior Consultant, Peter Hibbert, delves into what Just Culture truly entails, or rather, what it should embody.

What is Just Culture?
The tendency to assign blame is deeply ingrained in human nature. It provides us with a sense of superiority and satisfaction, as Professor James Reason aptly noted, "blame is such a delicious emotion"(1). Consequently, blame often becomes our default response to human failings. From a young age, we are conditioned to expect blame as both a reaction and a method of addressing mistakes and shortcomings.

Dr David Marx said in sport, if someone makes an error they are often punished; this can lead to losing the match, race or game, and yet in life do we expect the person that makes the error to lose the game? So, what should the framework of justice look like when we are asked to stand in judgement against our fellow human beings?(2)

FAiR Tool: How it Supports Just Culture
Many aviation organisations use a framework, such as the Baines Simmons FAiR Tool, to take care of Just Culture, and whilst FAiR greatly helps support a Just Culture at the organisational level, it does nothing to support a Just Culture at the personal day-to-day interaction level.

You may have heard the story of Elaine Bromley as it is often covered in safety training. Elaine was tragically killed whilst undergoing routine surgery in an NHS hospital. She died in a well-equipped modern hospital because of a simple error, and her husband Martin didn't want anyone blamed. He wanted the individuals who made the error to continue their careers as medical practitioners, without any blemish on their records, why? They were the ones who would never do it again; they were the ones who would educate others.(3)

Given what happened to Elaine, I wonder how many of us would be able to support a Just Culture to that extent. I very nearly found out when my father was once in hospital. He'd been quite poorly but he was getting better, and the doctors had started to talk about discharging him. My sister and brother-in-law had gone to see him, and I was working 200 miles away when my sister called me and said, "Get here now if you want to say goodbye to Dad". As I started thinking about the four-hour drive and how I wouldn't make it in time, she said, "Hang on, a doctor is waving his arms at us, I'll call you back in a minute". Five minutes later she called back; I was expecting the worst and to my surprise, she said, "Don't worry, he's going to be fine". At this point I was a little confused, as within a few minutes it had gone from my Dad dying to everything is ok. 

We learnt that the reason my 80 year-old father had gone from a steady recovery to asking for his mother was the result of an accidental 10x drug overdose, and now this was known, the doctors concluded that he would be fine. The next thing my sister said down the phone was, "I have been handed some paperwork on how to sue the hospital, what do you think?".

Thankfully, just as I was starting to think about a new car, my brother-in-law, who works in aviation, shouted down the phone, "Just Culture, Pete". And he was right, a nurse had made an error. We didn't sue, but to this day, I wonder if that error had killed my father, would I have been strong enough, like Martin Bromley, not to sue? Would my respect and understanding of what a Just Culture really is have stood the test? I'm not sure but I hope it would have. 

Within the UK's National Health Service, there have been many incidents of accidental drug overdoses. At Civility Saves Lives, Dr Chris Turner recalls one such event where a little girl was given a 40x drug overdose of a very toxic drug called Aminophylline. Thankfully, she survived, and the NHS launched an investigation, which concluded that the nurses administering the drug had not been competent and they were sent for some training. However, that wasn't the whole story, the investigation missed something. As the nurses were preparing to administer the drug, they twice asked the attending paediatric doctor about the correct dosage, and twice they were snapped at. 

Many of us work in teams, often in dynamic complex environments, and studies into teamwork have found that the biggest factor in performance detriment, in normally high-performing teams, is incivility or rudeness. 

Just Culture in the Aviation Industry
Aviation safety companies employ competent, knowledgeable, diligent professionals and on a good day, most of us can deal with around 5 to 7 things at once. However, add in a personal and company distraction and that 5 to 7 quickly becomes a capacity of 3 or 4. Then, add in what happens when someone is openly rude to us. Our bandwidth reduces and the ability to deal with 3 or 4 things at once becomes 1 or 2, and we are now in primer error-making territory.

So, what has this got to do with Just Culture? I would argue that it is very much part of it; a Just Culture isn't something that only kicks in after an event, it should be a culture of understanding and tolerance all around us all the time. In aviation, we talk about Human Factors and Human Performance, and if we want the latter, we must support people and not belittle them. 

I'm sure many of us will openly espouse a Just Culture, yet 'verbal leakage' in our everyday, unguarded language often demonstrates a disjoint in our underlying beliefs, "Who did that?", "Which idiot screwed up this time?". Comments and even thoughts like this demonstrate that we are personally struggling to be just. 

When visiting aviation organisations, I often come across a perception that Just Culture is about how someone should be treated after an event. I hear comments such as we have a "Just Culture because we have the FAiR system", and yet I would argue, that you do not have a Just Culture unless people can hold their hands up and say, "I've made an error or even I'm having to break the rules to complete our tasking" (which we know happens in many aviation organisations daily), and in doing so, they know that even if they're a young mechanic saying this to a supervisor, they will be treated fairly.

An effective Just Culture should permeate our daily personal interactions, fostering an environment conducive to success. It serves as a supportive framework that enhances Human Performance. Simplifying the concept into a Trust Culture underscores the essence of fairness and mutual respect. In such a culture, trust should prevail in every interaction, whether it's between individuals or between individuals and organisations. 

Contact us at to find out how our experienced team can work with your organisation to help build, operate and drive Just Culture performance. 

(1) - Professor James Reason
(2) - Dr David Marx, Whack a Mole, ISBN: 9780990895602
(3) -  Martin Bromley talking about a Just Culture -