Signal Charlie

“In my view, a safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behavior and blameless unsafe acts. There sill always be a grey area between these two extremes where the issue has to be decided on a case by case basis. This is where the guidelines provided by A Roadmap to a Just Culture will be of great value. A number of organisations have embarked upon this process, and the general indications are that only around 10 percent of actions contributing to bad events are judged as culpable. In principle, at least, this means that the large majority of unsafe acts can be reported without fear of sanction. Once this crucial trust has been established, the organisation begins to have a reporting culture, something that the system with an accessible memory, which, in turn, is the essential underpinning to a learning culture. There will, of course, be setbacks along the way. But engineering a just culture is the all-important early step; so much else depends on it.” (Reason, James, Forword to A Roadmap to a Just Culture, GAIN, 2004)

Roadmap Reprinted with permission from the Global Aviation Information Network GAIN