Implementing A Just Culture: Simple But Complex


A Just Culture policy that management is still trying to visualize and cannot fully define is a lost opportunity to enhancing safety within an organization.

The concept of Just Culture presents the idea that employees should not be punished for making an honest mistake while clearly identifying what are unacceptable acts. That idea, combined with trust within an organization, is the foundation of a good Safety Culture, which, in turn, is the key for managing safety in complex organizations.  Trust, in its simplest definition, is Truth over Time.

But for a good Safety Culture to thrive, and Just Culture to be fully accepted, three questions must be addressed: 

  • How do we differentiate between an honest mistake and normal employee conduct and performance?
  • How do we embrace Just Culture concepts while accepting the principle that the organization, as a legal entity, still has responsibility for the results of the mistake?
  • How do we implement a Just Culture policy so that in time it becomes a way of life and not simply a quid-pro-quo between management and labor?

Let’s explore some potential complexities involved

Just Culture thrives on the acceptance of a basic principle that all humans, by our very nature, will make unintended mistakes due to factors often outside of our control. Complex procedures, time pressure, a 24/7 operation, unclear guidance, personal pressures – all of these can influence individual performance that could lead to an honest mistake – none of which should justify punishment of the individual.

But we need to delve deeper into how a mistake can cascade and become more complicated. This exploration will allow us to extend fairness even further – to accept that people should not be punished for an inadvertent mistake, but that any negative impact from mistakes must be addressed so people affected by the mistake are not burdened, and so the organization can improve its future performance. 

Consider four examples of unintended mistakes – some humorous, some very serious.

  • An airline passenger checks a bag and pays a fee, expecting the bag to arrive at the same destination at the same time – but it shows up four days later in a different city.
  • A new shipping dispatcher is told to “send it to Dallas.” The delivery is made to Dallas, Texas, when the intended destination was Dallas, Pennsylvania – an error of 1,493 miles.
  • An Air Traffic Controller tells an aircraft to “descend and maintain 11,000 feet.”  The pilot acknowledges, “Roger, descending to 10,000,” and the controller does not catch the pilot’s readback mistake. The aircraft then descends and conflicts with another aircraft, resulting in both taking evasive action and narrowly avoiding a collision in midair.
  • An emergency room physician on a 24-hour shift with multiple critical patients administers penicillin to a patient without fully checking the medical record. The patient has an allergic reaction and almost dies.

With some events, saying “Sorry, it was just an honest mistake,” and immediately correcting the error can be acceptable and is generally the norm.  But in other cases, the event may be too extreme or complicated, or involve third parties, for a simple apology to be acceptable. To implement a Just Culture policy, one of the initial steps is to set up an internal process to examine and address how incidents are handled and developed within the organization, so all parties will know what to expect and what are their roles and responsibilities. 

The acceptance of responsibility is another critical part of that discussion. While society will strive to be fair to the individual, if Just Culture principles create the appearance of immunity from accountability – thereby making someone or some organization “above the law” – it will be resisted by the same society that will no longer see it as fair.

If we look at the four examples again and ask which are mistakes and which may indicate the individual was not able to perform the task, it adds significant complexity to the situation.

The role of Trust – everyone is involved

Employers are responsible for the actions of employees and, as such, should establish standards of conduct and performance as part of employment. Employees must be informed on these standards and willingly comply as part of their responsibility to their employer.

Unacceptable acts are generally the most egregious, and examples might include illegal use of drugs or alcohol on the job, deliberate acts to inflict harm, intentional falsification of documents, and criminal acts. Fortunately, these types of acts are very rare and addressing them should be straight-forward. 

While a policy on Just Culture must originate from, and be supported by, the highest level of management, it is not solely the purview of the C-Suite. Likewise, Senior Management should not expect subordinate managers and employees to understand the policy, or know how to implement it on a practical basis, without continuous guidance and support.

Everyone, from the CEO to the newest hire, has a responsibility to each other to maintain trust within their organization. Trust is the by-product of truth over time, which will take years to build … and only seconds to destroy. 

Truth starts by managers not blaming employees for honest mistakes, which is often done to deflect management responsibility. Truth is strengthened by employees not hiding behind policies to avoid accountability for their performance. It sounds basic, but it becomes complex when we start to look at some of the human factors involved within a Just Culture.  

All parties in the organization must be involved, especially supervisors and team leaders working on the front line daily who are instrumental to supporting employee success, organizational goals and policies, and the implementation of Just Culture principles. All ranks within the organization, including both labor and management, must be willing to work together for Just Culture to succeed.

Trust is imperative when more complex challenges arise from examining mistakes. We should always start with the assumption there was no intent to make a mistake. We then need to consider if the event was an isolated mistake, or an indication of something more worrying – especially if we see similar mistakes being made by different people. But eventually, all organizations will face difficult questions like:

  • Did we place good employees in the wrong positions for their skills? 
  • Have we created a system the makes people prone to mistakes?
  • Do we have an employee overwhelmed by changing demands and technology? 
  • Are we providing the right type of supervisory leadership and management support to help employees succeed?  
  • Are the mistakes an indication of something else?
  • Are the organization’s expectations realistic?
  • Is this a trend across other departments as well?
  • Are we seeing an increase in risk within the organization that needs to be addressed?
  • Is the “Accountable Executive” being accountable?

While all these questions may be appropriate, the most critical one is: “How do we address these concerns while maintaining the level of trust within the organization?”

This question is critical because it is very easy to slip backwards into a Blame Culture, from which an organization will never recover.  

The first step on a long journey

Trust is truth over time that builds a foundation of honesty within an organization. It is an extraordinarily difficult thing to do and becomes magic when it happens. Teams with trust become a powerful source of pride and capabilities – and the envy of others who may still be seeking that kind of relationship.

But developing trust requires people to do something very difficult – take that first step, trust someone else, and hope their effort will be reciprocated in kind. 

An ideal starting point is the solicitation of safety reports from front line personnel.  Knowing they will not be punished for making an honest mistake opens the door for the identification of risks the organization may never otherwise have known until it resulted in a major unwanted event. Management should solicit these reports and labor organizations should encourage members to report. Nobody should be surprised by – or overreact – to the increasing number of safety reports. Ironically, the number of reports going UP is a GOOD indication!

These reports allow for the organization to take proactive corrective measures to mitigate risk, thus protecting employees – and others – from potential harm. 

Over time, that scenario is repeated, again and again, with truth shown by all parties and increasing enthusiasm for the process and pride in the organization. It’s at that point everyone in the organization will realize they do, in fact, have a policy of Just Culture.