Just culture

Principles and distinction of conduct

• Human error. Unintentional failure of action or judgment (oversights, lapses, mistakes) in trained individuals who intended to do their job well; the response is system redesign, training and support, never punishment.
• Risky behavior or violation of procedures. Conscious deviation from a norm, often routine, situational, or to optimize work; the organizational causes (inapplicable procedures, time pressure, management tolerance) are analyzed and corrected, with a focus on the individual.
• Gross negligence and intentional conduct. Manifest and serious breach of the duty of care with foreseeable harm, or deliberate infringement; these are the only behaviors that justify a disciplinary response.
• Substitution test. Criterion for evaluating a case: ask yourself if a person with the same qualifications, in the same circumstances, would have acted similarly; if the answer is yes, the problem lies in the system.
• Trust and responsibility. A just culture is not an absence of responsibility: it publicly and in advance defines the boundary between acceptable and unacceptable and applies it consistently.
• Learning. The goal is to obtain information about system failures before they cause harm and close the loop with measures and feedback.

References in aviation and occupational safety and health

In the field of civil aviation, Regulation (EU) 376/2014 defines a just culture, obliges organizations to establish mandatory and voluntary reporting systems, requires that information be used solely to improve safety, and establishes in its Article 16 the protection of the source: Member States must refrain from initiating proceedings for unintentional or inadvertent infringements that are only known through notification, except in cases of willful misconduct or gross negligence, and employers may not harm the person who reports. In Spain, Law 21/2003 on Air Safety and the State Aviation Safety Agency, through its just culture policy, apply these principles with a collegial procedure to determine when conduct loses its protection.

In occupational safety and health, there is no specific standard on a just culture, but several instruments point in the same direction: Law 31/1995 requires investigating health damages and integrating prevention into the organization, and prohibits workers from suffering harm for their preventive actions; ISO 45001 requires that senior management protect workers from retaliation when they report incidents, hazards, risks, and opportunities, and that the organization investigate incidents and non-conformities; and Law 2/2023 on the protection of whistleblowers prohibits retaliation against those who report serious infringements through the established channels and requires entities with fifty or more employees to have an internal information system.

Elements of a just culture in the company

• Written and public policy. Statement from management, agreed with the workers’ representatives, that defines acceptable and unacceptable conduct, the assessment procedure, and the guarantees for the person reporting.
• Accessible reporting system. Simple, confidential channels where appropriate, for incidents, near misses, hazardous conditions and proposals, separate from the disciplinary sphere.
• Systems-oriented research. Analysis of organizational, technical, and human causes using structured methods and with the participation of the people involved.
• Critical assessment of behaviors. Use of tools such as Reason’s decision tree or the substitution test, applied by trained personnel and with consistency between cases.
• Feedback. Communication to the staff of what has been reported, what has been learned, and the measures taken, which is what sustains confidence in the system.
• Leadership training. Middle managers are the ones who receive the first notifications and determine through their reaction whether the just culture is real.

Organizational application: how to implement a just culture

1. Obtain management commitment and agree with worker representatives on a just culture policy that defines acceptable and unacceptable behaviors and guarantees for those who report.
2. Design or review the system for reporting incidents, near misses, and hazardous conditions, separating it from the disciplinary procedure and ensuring confidentiality where appropriate.
3. Define the procedure for assessing behaviors with explicit criteria (substitution test, decision tree) and with a collegiate body or people trained to apply it.
4. Train middle managers in receiving notifications, in system-oriented investigation, and in non-punitive response to error.
5. Investigate the events using structured methods and with the participation of the people involved, looking for organizational and technical causes.
6. Close the cycle with measures, deadlines and responsible parties, and communicate to the staff what has been notified, learned and corrected.
7. Measure the evolution (number and quality of notifications, response time, staff perception) and review the policy periodically.

Preventive management software allows you to offer notification channels accessible from any device, record and classify events, manage the investigation and its causes, plan the measures and their follow-up, communicate feedback to the staff and analyze notification indicators by center and area, with traceability and access control that protect confidentiality.

Limits and common mistakes

1. Confusing a just culture with a culture without responsibility: the boundary with gross negligence and intentional conduct must exist and be enforced.
2. Declaring the policy and maintaining the punitive reactions of the command staff to the error, which nullifies trust in the system.
3. Using the notification system as a source of disciplinary evidence or not separating both areas.
4. Assessing behaviors on a case-by-case basis without prior criteria or consistency, generating a perception of arbitrariness.
5. Do not return information to the staff regarding what was reported and corrected.
6. Transferring the aviation model without adapting it to the reality of the company, its agreement and its labor regulations.

The application of a just culture must respect labor regulations, the disciplinary regime of the agreement and data protection; this sheet is for informational purposes.

Regulatory and reference framework

• Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. Notification , analysis and follow-up of incidents in civil aviation; definition of just culture and protection of the source (Article 16).
• AESA. Fair Culture . Fair Culture Policy of the State Aviation Safety Agency.
• AESA. Guidance material MG-2015/001. Just culture . Distinction between error, risky conduct and gross negligence and recommended practices for organizations.
• Law 21/2003, of July 7. Air Safety; protection of operational safety information.
• Law 31/1995, of November 8. Law on the Prevention of Occupational Risks; investigation of damages, integration of prevention and guarantees for workers.
• ISO 45001:2018 . Occupational health and safety management systems; protection against retaliation for reporting and incident investigation.
• Law 2/2023, of February 20. Protection of persons who report regulatory infringements; prohibition of reprisals and internal information system.

A just culture is not a specific legal requirement in occupational safety and health; its application is supported by general obligations of investigation, participation and protection from retaliation and by references from high-reliability sectors.