International Helicopter Safety Team Safety Management System Toolkit

Non-compliance rarely results in
an accident or incident, however:
It always results in a greater
risk for the operation!
Just Culture Process
Management must promote a non-punitive working
environment. This is referred to as a “Just
Culture.” A non-punitive environment is fundamental
to having a good reporting culture. Employees
must know and agree on what is acceptable and
what is unacceptable behavior. Management must
not tolerate negligence or deliberative violations. A
just culture recognizes, that in certain circumstances,
there may be a need for punitive action
and attempts to define the line between acceptable
and unacceptable actions or activities.
Non-Punitive
Disciplinary Policy
It is recognized that humans will make errors and
systems must be developed that are error tolerant
and behaviors changed to lessen the chance of
errors occurring.
It is not the goal of policy to seek out the guilty
party in order to administer retribution for the error.
The goal is not to punish, but to ensure it does not
happen again.
The organization should strive to develop a nonpunitive
disciplinary policy as part of its safety
management system. Employees are more likely to
report events and cooperate in an investigation when
some level of immunity from disciplinary action is
offered. When considering the application of a nonpunitive
disciplinary policy, the organization should
consider whether the event involved willful intent on
the part of the individual involved.
THE LETHAL COCKTAIL: The Main Predictors
Expectation: Expectation that rules will have to be bent to get the
work done.
Powerfulness: The feeling that one has the ability and experience to do
the job without slavishly following the procedures.
Opportunities: Seeing opportunities that present themselves for short
cuts or to do things “better.”
Planning: Inadequate work planning and advance preparation,
leading to working ‘on the fly’ and solving problems as
they arise.
Courtesy of Patrick Hudson, PhD, Leiden University - CHC 2009 Safety Summit
56 SMS Toolkit