Fireside Chat: How to Develop Just Culture

How to Develop a Just Culture with Henrik Löfqvist Web Manuals Petter Nyholm Preflight Niclas Eriksson

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Fireside Chat: How to Develop Just Culture

At Web Manuals, our purpose is to enhance our clients’ success, flight safety and happiness. To join us in this initiative recently welcomed Preflight to be our new partner in aviation safety and compliance matters. During initial conversations, we discussed the importance of a safety-first mindset from a management perspective – to create an outstanding safety culture where even the smallest incidents need to be reported to reduce future accidents and damage to persons and property.

While we at Web Manuals hope that tools such as our forms manager simplifies the reporting process, we understand that developing a Just Culture requires a lot more than tools. That is the background on how this initiative came to be.

To speak on this topic, we invited Petter Nyholm, the founder of Preflight, as well as Niclas Carlsson, the Safety Manager of OSM Aviation Academy, our customer as well as the very place where Henrik did his flight training back in the days.

Niclas, Petter, and Henrik speak on Just Culture from a manager, instructor and student perspective. See the fireside chat below or browse highlights in the text below.


Petter Nyholm – Preflight AS

“My name is Petter Nyholm – I come from an aviation background. I have over 15 years within aviation, most of it from helicopter area work but also as an instructor.

I’m the founder of Preflight – I founded that the company with an old colleague of mine, and we work with training, safety and compliance matters within the aviation industry.”

Niclas Eriksson – OSM Aviation Academy

“My name is Niclas Eriksson – I’m the Safety Manager at OSM Aviation Academy. Also aviation background, but more fixed wing. I’ve been within aviation since 2008 and worked on it as an instructor for many years.

Now since two years back, I’ve been the safety manager of the company.”

Introduction of Just Culture

Let’s look at the safety system as a whole. What is it that we actually want to prevent with the safety system?Usually it’s accidents or damage to persons or property or equipment – and on top of the list, we find regulations.

The regulations are there to try to prevent all of these things from happening, but we know for a fact that the regulations are not enough. There are many reasons for that – could be attitudes, it could be pressure, it could be company cultures and so on. And just writing a regulation will typically not be enough, because it has to be followed.

Another thing with regulations is that they are usually written after an accident. So, something has happened before we want to prevent that from happening again. But if we would like to prevent things that have not yet happened, we have to dig a little deeper.

In order to to follow the regulations, we have, for example, the compliance manager who makes sure that the regulations are followed within the company. Then we have the safety manager, focusing on safety as its sole purpose. But there are many, many parts within the system that has to work and it will not be enough just to have the the safety manager and the compliance manager. They also have to know what is not working within the organisation as a whole.

For that you need a recording system. And it has to be a recording system within each organisation. But the degree of what is recorded within the system will vary between organizations – and that’s where you will find just culture.

The more just culture you have within the organisation, the more things you will find within the reporting system, which is the tool to be used for the safety manager and the organisation to prevent accidents from happening, and the opposite. If you don’t have a just culture, you will not find out about the things that are happening within the company.

Definition of Just Culture

Just Culture is one where employees, and students in our case, feel that they are able to speak up when something goes wrong. They trust that the organisation will not punish them for the actual event that has happened and feel comfortable bringing up his mistakes or safety and quality concerns with us – so that we can learn from it.

Basically, we as a company, we need to create that trust with every employees and every students so that they actually report these types of events. So we can learn from it and we can make sure no mistakes are being hidden.

Just Culture is defining the relation as a culture, where a person is not being punished for actions or decisions taken by them, as long as they are open and honest of the mistakes. But it’s also a culture where illegal acts and willingly/knowingly violating rules or putting yourself in a dangerous situation is not tolerated.

Just Culture is basically a fair culture. 99.9% it is exactly the same as a no blame culture, where a person has done mistakes, they report these types of mistakes, and then the organisation tries to learn from those mistakes. The biggest difference from a no-blame culture is when setting a Just Culture, we have that 0.1%, where a person has jumped on something dangerous or illegal, knowing what the outcome might be and willingly still doing it. In that case, it has to be severe sanctions for that person.

The Opposite of Just Culture – Unjust Culture

It is when the employees are getting punished somehow when they’re doing mistakes.

You can’t get away from mistakes, it’s human. All humans will make mistakes and if you are punishing all mistakes, somehow, the employees will learn that in this company, you’re not allowed to do mistakes. So the employees will tend to not report their mistakes. And if they have to report, they will tend to blame something else, not themselves. Because if they were to blame themselves, they are afraid to get punished.

Basically, the opposite of just culture is when the employees are afraid to report.

Responsible Person for Developing a Just Culture?

Developing a Just Culture is a lot up to management for creating the culture. But once you have your culture in the company it is everyone’s responsibility. As an employee or a student, you’re responsible for reporting incidents or mistakes, and also safety or quality concerns in the reporting system.

The employer is responsible, first of all, to facilitate some type of system for reporting and also to give feedback on the types of reports. Because it’s one thing that the employees or students feel we have trust in the company to actually report the mistakes, but in order to have more reports, and actually getting a better your score, it’s very important to give feedback on the reports that you receive as a company. If you receive a report on one type of incidents, actually give feedback back to the reporter on what type of actions have been taken within the company to prevents these incidents in the future.

If you have those two things in place, you’re pretty far in a Just Culture.

In order to develop a good just culture and beginning reporting both big things and minor things is a great way to actually feel that people encourage people to report things, even if it’s minor. Because in that case, you get a lot of reports if you push them to report minor things as well.

Within the OSM Aviation Academy, we aim to receive around five reports per 100 flight hours, we have seen that if we have that, we have a very good level of reporting. So we are actually monitoring demand reports that we receive each month. And if we see that that number drops below five, we take some actions, maybe we have some more safety seminars with the students where the employees will send out more information to advertise the safety management system. And then sometimes maybe we get a lot more than five reports but we see that as a good lower limit.

Developing Just Culture

First Steps

The management have to first define the just culture and get it into the operations manual and put focus on it within a company. That’s step one. But that’s not enough. Because if you have actions that are not in line with Just Culture, the employees will see that they’re not treated fairly. And then, it doesn’t matter if it’s defined within the operations manual, it has to be applied with the correct actions from the management as well. Actions are actually more important than what is written within the operations manual.

Set up Training

In order to do that, the first thing is training, both for employees and students as well. For example, in OSM Aviation Academy, we have, at least once a year, a safety training for the employees where we go through the culture and policies that we have within the company. It acts a very good reminder to see what type of tools we have within the company to work with safety, but also as a very good reminder for the people to actually see that we’re still in progress with Just Culture.

Give Feedback

Another very important thing is implementing a process of giving feedback for the reports that come in, because again, that creates a very open and honest system. Because we have the responsibility for our employees and students to report the event and being open and honest all the time. But we as a company must also be open and honest towards the employees and students.

Show Trends

A way of doing that is basically having meetings where we go through the statistics of the reports, showing the trends that we receive. We are open what type of things that we see that we can improve and discuss that with the students. They see that the reports, again, is actually being looked at. Because if the students or employees does not feel that their reports being looked at, and they don’t get the feedback for the reports, t people will stop reporting, because they don’t feel that it helps.

A lot of companies, they might work a lot with the statistics and with the trends of the report but doesn’t show them to the employees. That can easily create a bad just culture.

Consider Pilot’s Ego

One problem with developing a just culture is the pilot’s ego. Typically, pilots have big egos, and they might need to have because they are in charge, right? They have to make decisions, they have to make hard decisions. So, big ego might be needed sometimes. But when it comes to reporting your mistakes, that might be a proble. Because whenyou don’t want to hurt your own ego, you don’t want to write that report that says, ‘I just forgot to do this thing’, as they don’t want to hurt their image within the company.

But the whole purpose with Just Culture is that all employees should feel like, it’s no problem for me to report the mistake I made, it is not going to make me look stupid and bad, because this is common within this company. And we all do it because we know that it’s human and we just want to enhance safety. That’s the whole goal.

You want pilots and the employees to report things where they blame themselves, which is hard. But then when the report is written, you basically want the organisation to say, ‘thank you for recording this and thank you for blaming yourself, but we think this is a system error’.

Now you want the organisation to blame themselves, which could also be a problem if there is an organisation or legal where the organisation thinks that they are not doing mistakes. So you have this ego thing, which is quite a big problem and needs to be considered.

From an ATO perspective, that’s the important thing – to actually start working with Just Culture from the beginning of training. From the first step that take into the fight school, start with explaining Just Culture, start with reporting their mistakes and encourage to report the mistakes so they can learn from it.

So others can learn from it and we can share that experience because if you can get that buried into the spinal behaviour of the students, from the beginning, it can really improve the way you think when it comes to bigger airlines and when you’re a captain and first officer later on.

Zero Reports  ≠ Zero Inccidents

As far as accidents go, it’s very good to have a zero accident goal or policy where you aim to have no accidents, but that must not be equal to zero reports, which sometimes tends to be a misunderstanding.

Sometimes management thinks that if we have less reports, that means things are going well, which is not true. Basically you want to have more reports, so you can enhance safety to prevent accidents and get your goal with zero accidents – you need more reverse.

At OSM Aviation Academy, we receive around 800 to 1000 reports per year. And that is a number we are proud of. It shows that people are honest, it shows that the system is working. Now we are reporting things.

We want a lot of reports from minor things. One minor thing might be nothing, but if you receive one hundreds of minor things, they can actually be a quality or a safety concern within the company and those things can easily build up. So it’s important to actually monitor the trend.

We have a trend tool within the company. When we close each report, it’s added to the trend tool. We can see how many things of each we have within a set timeframe. But of course, if you have bigger things, then maybe one report is enough to actually take stronger actions immediately.

Study Employee Behavior

Actually creating this great atmosphere where people admit their mistakes, we usually talk to that employee and the student and ask them if they want to stand up in front of the class and actually discuss this scenario, what led up to the mistake and what happens with a mistake and whatever they learned from it. Some cases, the student doesn’t want to do this. And then of course, we’re not going to force them to do it. But then we might use the report in an anonymous form as an example within the training to join it but in the case that the students or employees want to actually discuss the situation, that’s great. Because that really shows that it’s not an issue of standing in front of the class and discussing mistakes that you have done. It is a great way toactually improving the culture within the company.

Also, a good way to measure how good Just Culture you have within the company is to study the behaviour of employees. If you have a company where only management is the one who pushing and reporting, then it is only the management pushing for the Just Culture. You want to reach a level where the employees is pushing each other and encourage each other to write the reports and discussing situations, then you have a very very satisfied Just Cultural within the company.

Personlize First Response

Another good thing from management to analyze is how the report is handled – like the first response. When you write a report, it’s very important that the first response is good. An example of that, where the flight operations manager was very good and he developed a very just culture, is when there was a report written, he would call and he would ask the pilot; How are you? How did that feel? That must have been horrible, horrifying – and just talk about the experience from the pilots perspective.

He didn’t care about the mistakes or what did you did and why did you do that. That would be a wrong first response. No matter what management position you’re in, if you get a report, and you handle it in a negative way, directly, that will have a big impact on the employees.

Actually show what your priority priorities are in the first meeting, asking the person how they feel before you get into the actual event. OSM Aviation Academy have a similar case meeting where when we have more serious incidents. The first meeting is usually done off the school. Maybe at a coffee shop somewhere in civilian clothing, just to put that the restrictive level off.

From a student’s perspective, it’s very reassuring to see because classmates talk a lot about things happening. If you send in a report that you see that a classmate not get punished for – even just a simple, easy thing – that will then spread to the rest of the class.At OSM Aviation Academy, for example, being several classes at the same school, this would then even spread to other classes as well, because there’s a lot of communication going on.

Simplify Reporting Process

Having a nice and easy place to write the reports and having it preferably done the same day when you have everything fresh in your mind is also very important. Instead of waiting and having a complicated process of writing the report.

Encourage Role Models

The more experienced pilot or employee that reports the mistake, the better because the other ones will look up this person and say okay, if he is reporting or she’s reporting these mistakes, well, then I can do it as well.

Hire Outside Firm

Finally, the development of a Just Culture is pretty hard and it takes time. You have to consistently do the right thing for a long time. And it can also be hard to know if you have a Just Culture because the whole problem with a Just Culture is that people will not speak up because they are afraid to get punished. So you will not hear from the employees that you have an Unjust Culture within the organisation.

It’s a good idea to get an outside firm to do an analysis to see where you are with Just Culture – and we at Preflight can do that. It’s a good starting point just to know where you are, and then there are a lot of things you can do step-by-step to develop a just culture.