Instructional material for practical application in SMS work: Just Culture decision-making charts

Just Culture – an important building block of safe operations

This page contains decision-making charts that organisations can use to improve the inclusion of Just Culture in their safety management. The box below contains two decision-making charts from different perspectives. Below them, there are examples of decision-making and processing of occurrence reports and events in imaginary organisations (airline, ground handling company and provider of air navigation services).

Just culture perspective: decision-making charts supporting organisations’ safety management

The charts below have been adapted from the publication “GAIN working group - Roadmap to a Just Culture - Enhancing the Safety Environment” (1997).The chart was modified on the basis of authorisation given byGlobal Aviation Information Network in the document in question (“Derived from a document for which permission to reprint was given by the Global Aviation Information Network”).

Decision-making chart – Just Culture

The chart can be utilised in situations where the possibility of deliberateness or gross negligence in misconduct endangering or potentially endangering safety must be verified.

Decision-making chart – Just Culture as part of safety management (SMS)

The chart depicts the principles of processing occurrences in aviation in an organisation so that Just Culture is included in the safety management system (SMS). The chart focuses on utilising safety information produced by personnel in ensuring and improving safety.

Decision-making chart – Just Culture (pdf, 564 kt)Decision-making chart – Just Culture as part of safety management (pdf, 612 kt)

Examples of using the decision-making chart “Just Culture as part of safety management

Each example depicts a situation that has led to the occurrence report filed by the employee(s) involved in the incident and the processing of the occurrence in the organisation. Both the organisation and the event and related examples are fictitious. However, they represent realistic situations and operations models. There are three different approaches to processing each event: CASE GREEN, CASE GREY and CASE RED. You can find a more detailed definition for each approach below.

CASE GREEN: describes an example of confidential and solution-oriented case handling in the organization in the spirit of just culture and a good safety culture. The organization genuinely recognizes its own role in solving the problem and uses the case as an information source for safety management system (SMS) in its risk management and assuring safety. The reporters of the occurrence are given appropriate feedback on the processing steps. The risk management measures aimed at the individual are justified in a genuine and honest way (e.g. possible additional training).

CASE GREY: describes an example of handling a case in an organization in a situation where the organization does not recognize its own responsibility in the solution, the root cause analysis is left superficial, i.e. the real problem remains uncorrected and the corrective measures are "cheap and easy" so that the handling of the case can be "closed". Feedback to the authors of the occurrence report comes only through an automatic response.

CASE RED: describes an example of handling a case in an organization in a situation where the organization does not recognize its own responsibility in the solution, the causes of the case are only looked for in the actions of the crew (individuals) and the real problem remains uncorrected. The crew is blamed and the matter is handled in a non-confidential spirit.

Example: flight operations

The examples below (CASE GREEN, GREY and RED) concern the same imaginary event in the same imaginary airline with the same basic information. The examples differ by how the organisation processed the event as part of its safety management. These differences lead to three different outcomes for both the persons involved in the event and the organisation.

OPS-CASE-decision making as part of safety management - CASE GREEN (pdf, 92 kt)OPS-CASE-decision making as part of safety management - CASE GREY (pdf, 855 kt)OPS-CASE-decision making as part of safety management - CASE RED (pdf, 859 kt)

Example: ground handling

The examples below (CASE GREEN, GREY and RED) concern the same imaginary event in the same imaginary ground handling company with the same basic information. The examples differ by how the organisation processed the event as part of its safety management. These differences lead to three different outcomes for both the persons involved in the event and the organisation.

GH-CASE-decision making as part of safety management - CASE GREEN (pdf, 843 kt)GH-CASE-decision making as part of safety management - CASE GREY (pdf, 844 kt)GH-CASE-decision making as part of safety management - CASE RED (pdf, 846 kt)

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