Just Culture and the Role of Accountability Continued from page 39 than inventing new ways to deflect liability. We’re able to bid more competitively and exceed service expectations if we can more effec- tively enable real-time learning and push toward restoration rather than punishment. But, this is hard work. It involves continuous effort, balanc- ing the tension between, as Dekker notes, “wanting everything in the open, but not tolerating everything” (2016, p. 26). Internally, investing in growing a just culture builds trust and transparency. These are important because there’s little doubt who will be called to the boss’s office when something goes wrong. Front-line employees have the most at stake because of their proximity to work at the sharp end, and they stand to gain the most from a system that exam- ines not only why a system fails, but how they build capacity for things to go right. That context, if mistreated, can be fatal for an organization, but with thoughtful implementation, workers at all levels have an oppor- tunity, not for exoneration, but to focus on doing their work well with an understanding that the organiza- tion wants to hear an honest assess- ment of how things look from where they sit, allowing more informed decision-making from top to bottom. Rashomon, the classic 1950 Kurosawa film, examines the concept of justice by taking viewers through the same events as viewed by four people, each with a different—and sometimes contradictory—perspec- tive. The movie builds suspense because we see how murky the waters can become around the topics of trust, objectivity, blame and report- ing. Growing a just culture is more Aviation Business Journal | 3rd Quarter 2018 Just culture shifts our perspective to understanding from the bottom up than simply balancing culpability and accountability; it also requires a balance of perspective (the earlier examples certainly had many per- spectives involved) and a willingness to defer to local, front-line wisdom as to how processes are done and where the system fails or supports employ- ees in the completion of their work. Building perspective-broadening opportunities into our processes is just one way to work toward a culture of balanced accountability. PEOPLE CREATE SAFETY If we choose to view people and their actions as problems, we are willfully ignorant of the preponder- ance of evidence pointing to human flexibility and ingenuity as creat- ing the resilience necessary for our organizations to make it through even a single shift without disaster. As an example, we’re frequently told that human error is causal in the bulk of incidents and accidents (there’s a fun- damental problem here, in that error isn’t a cause, but a hindsight-biased label applied to describe a condi- tion—more on that in ABJ Q3 2015, if you’re interested). Assuming no logical issues with that first statement on human error, we know that acci- dents, at least in the case of readily available Part 135 accident rates, occur on only around 22 occasions per million flight hours. If humans are to blame in those arguably rare occurrences, then what causes things to go right—or at least unremark- ably—99.99998% of the time? For our logic to work, the answer has to be humans, and for a just culture to emerge, we must likewise under- stand that humans create safety. Too far to the other end of the spectrum, toward a truly blame-free environment, may not satisfy the many pressures we face in business, nor does it address a core principle in any organization: accountabil- ity. With an aircraft lying in the grass after an overrun, the board of directors will almost certainly seek an explanation as to exactly how the accident occurred, and who should be punished (or worse yet, retrained with the same systems that got them there to begin with). We see this echoed in society as well, where clear calls for accountability result in swift, often crowd-sourced, Continued on page 43 41
