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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

HFACS and Wildland Fatality Investigations

Hugh Carson wrote this article a few days after the Cramer Fire

Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report

A Roadmap to a Just Culture: Enhancing the Safety Environment

Cover and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form

Rainbow Springs Fire, 1984 — Incident Commander Narration

Years Prior
April 25th
Fire Narrative
Lessons Learned

U.S. Forest Service Fire Suppression: Foundational Doctrine

Tools to Identify Lessons Learned

An FAA website presents 3 tools to identify lessons learned from accidents. The site also includes an animated illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."

A Roadmap to a Just Culture:
Enhancing the Safety Environment

Prepared by: GAIN Working Group E,
Flight Ops/ATC Ops Safety Information Sharing

First Edition • September 2004

3. Creating a Just Culture

3.1 Benefits of a Just Culture

The benefits that can be gained from the creation of a Just Culture in an organization include measurable effects such as increased event reports and corrective actions taken, as well as intangible organizational and managerial benefits:

Increased reporting

  • A Just Culture can lead to not only increased event reporting, particularly of previously unreported events, but also the identification of trends that will provide opportunities to address latent safety problems.
  • It has been estimated that for each major accident involving fatalities, there are as many as several hundred unreported incidents that, properly investigated, might have identified an underlying problem in time to prevent the accident. (GAIN Operator’s Flight Safety Handbook, 1999)
  • A lack of reported events is not indicative of a safe operation, and likewise, an increase in reported events is not indicative of a decrease in safety. Event reporting illuminates potential safety concerns, and any increase in such reporting should be seen as a healthy safety indicator.
  • Peter Majgard Nørbjerg of Naviair, Denmark’s air traffic service provider, reported that after a June 2001 change to Denmark’s law making confidential and non-punitive reporting possible for aviation professionals, the number of reports in Danish air traffic control rose from approximately 15 per year to more than 900 in the first year alone.

Trust Building

  • The process of clearly establishing acceptable versus unacceptable behavior, if done properly in a collaborative environment, brings together different members of an organization that often have infrequent contact in policy decision-making. This contact, as well as the resulting common understanding of where the lines are drawn for punitive actions, enhances the trust that is at the core of developing Just Culture.
  • Patrick Hudson noted in 2001 that “most violations are caused by a desire to please rather than willfulness.” This observation emphasizes the inherent nature of the majority of safety violations: (i) that they are indeed inadvertent and (ii) that they are intended to further the organization’s operational objectives. This fact is well known on the “front lines” of an airline or air traffic service provider, but is often obscured further up in the management structure, particularly during an investigation of a violation or accident. Likewise, front-line workers may not have a clear understanding of which procedures are “red light” rules (never to be broken) and which are “yellow light” rules (expected to be broken, but will be punished if an accident occurs). Establishing a well-defined, well-monitored Just Culture will help all members of an organization to better define their own responsibilities and understand the roles, influences, and motivations of others in the organization.
  • It can be expected that a Just Culture will increase confidence of front-line employees in its management’s prioritization of safety over its interest in assigning blame. It will reinforce the organization’s common vision and values regarding the need to put safety first in all aspects of its operation.

More Effective Safety and Operational Management

  • It can be expected that a Just Culture will enhance the organization’s effectiveness by defining job performance expectations, establishing clear guidelines for the consequences of deviance from procedures, and promoting the continuous review of policies and procedures.
  • Just Culture can allow an organization to be better able to determine whether violations are occurring infrequently or if deviation from established procedures has become normalized among its front-line employees and supervisors.
  • Outdated or ineffective management structures can be manifested in many ways, as by operational inefficiencies, lost opportunities, or safety lapses. While Just Culture is primarily implemented by a safety motive, it is recognized “that the same factors which are creating accidents are creating production losses as well as quality and cost problems.” (Capt. Bertrand DeCourville, Air France, 1999)

3.2 What is expected to change in an organization with a Just Culture

The shift from the traditional “Blame Culture” to a more constructive “Just Culture” can be expected to have tangible benefits that will contribute positively to the overall safety culture of an organization by emphasizing two crucial, yet not mutually-exclusive, concepts:

  • Human error is inevitable and the system needs to be continually monitored and improved to accommodate those errors.
  • Individuals are accountable for their actions if they knowingly violate safety procedures or policies.

A Just Culture is necessary for an organization to effectively monitor the safety of its system both by understanding the effects of normal human error on the system and by demonstrating its resolve to enforce individual operator responsibility. This responsibility includes adherence to safety regulations as well as reporting inadvertent errors that can alert an organization to latent safety dangers. Operating with a Just Culture will create conditions conducive to reporting and collaborative decision-making regarding policy and procedural changes.

One example of the marked changes in an organization as a result of creation of Just Culture occurred at Naviair, the air traffic service provider in Denmark, made possible through a change in its national law. (Details are described in section 4.1)

Based on the experience of Naviair and others who have implemented Just Culture, the following values can be expected to be prevalent throughout the organization:

  • People at all levels understand the hazards and risk inherent in their operations and those with whom they interface.
  • Personnel continuously work to identify and control or manage hazards or potential hazards.
  • Errors are understood, efforts are made to eliminate potential errors from the system, and willful violations are not tolerated.
  • Employees and management understand and agree on what is acceptable and unacceptable.
  • Employees are encouraged to report safety hazards.
  • When hazards are reported, they are analyzed using a hazard-based methodology, and appropriate action is taken.
  • Hazards, and actions to control them, are tracked and reported at all levels of the organization.
  • Employees are encouraged to develop and apply their own skills and knowledge to enhance organizational safety.
  • Staff and management communicate openly and frequently concerning safety hazards.
  • Safety reports are presented to staff so that everyone learns the lessons.
  • Feedback is provided to users and the aviation community:
    • Acknowledgement – reporters like to know whether their report was received and what will happen to it, what to expect and when.
    • Feedback – it is important that the users see the benefits of their reporting in knowledge sharing. If not, the system will die out.

3.3 Creating and implementing a Just Culture

This section briefly describes some of the main steps as well as potential obstacles to achieving a Just Culture. These have come from a number of sources: including Reason (1997); Johnson (2003); lessons from the Danish experience; EUROCONTROL ESARR2 Workshops in 2000 and Vecchio-Sadus and Griffiths (2004).

1. Legal Aspects

In order to reduce the legal impediments to reporting, the two most important issues are: i) indemnity against disciplinary proceedings and ii) having a legal framework that supports reporting of incidents. The first steps in changing the legal aspects could be to:

  • Substantiate the current legal situation; does it need to be changed?
  • Discuss possibilities of change with company lawyers / legal advisors.
  • Discuss with operational personnel what changes in the legal policy they think would improve incident reporting.
Potential Obstacles: For many organizations, the main challenge of developing a Just Culture will be to change the legislation, especially if the changes are counter to societal legislation.

2. Reporting Policy and Procedures

It is important that the following issues are considered with regard to the underlying reporting structure and company commitment:

  • Confidentiality or de-identification of reports.
  • Separation of agency/department collecting and analyzing the reports from those bodies with the authority to institute disciplinary proceedings and impose sanctions.
  • Company commitment to safety.
  • Some degree of independence must be granted to the managers of the reporting system.
Potential Obstacles: Persuading senior management of the need for creating a Just Culture and to commit adequate resources to it may be difficult. For many organizations, the main challenge of developing a Just Culture will be to change the legislation, especially if the changes are counter to societal legislation.

3. Methods of Reporting

It is important that issues such as the following are considered with regard to the method by which reports will be collected:

  • Rapid, useful, accessible and intelligible feedback to the reporting community
  • Ease of making the report - voluntary reporting should not be perceived as an extra task
  • Clear and unambiguous directions for reporting and accessibility to reporting means
  • Professional handling of investigation and lesson dissemination

The first steps to develop a ‘Just Culture’ Reporting System could be:

  • Decide on voluntary versus mandatory reporting system
  • Decide on anonymous, confidential, open reporting system
  • Develop procedures for determining culpability (such as the Just Culture decision tree) and follow-up action (type of discipline or coaching)
  • Decide who shall decide culpability (e.g., team consists of safety; operations; management; HR)
  • Draft a plan and discuss with a small selection of operational personnel

Further Investigation

  • Decide if and how the reports will be further investigated (the focus of the investigation; face-to-face interview.)
  • Decide which reports will be further investigated (those which are most severe; or those with the most learning potential).
  • Decide who will investigate the reports.
Potential Obstacles: It may not be obvious to all organizations which system would suit them best. Ideally, a variety of reporting methods (or a flexible method) will be implemented, as not one reporting method will suit everyone’s needs. It may be necessary for the organization to survey the needs of the potential users to better understand which reporting method would be more readily accepted. A system that is unclear and ambiguous could create distrust in the system, so it is necessary that the procedures to decide culpability must be clear and understood by all. Reporters may not reveal their identity (e.g. in a confidential reporting system) or choose not to be interviewed, which could prevent any further investigation of an event.

4. Determine Roles and Responsibilities, Tasks and Timescale

For such a system to thrive, a number of different people need to be involved in the implementation and maintenance of the system. A ‘local champion’ will be needed to promote and act as guarantor to ensure the assurances of anonymity will be preserved in the face of external or managerial pressures. Decide and select someone to:

  • Champion the system • Educate users and implement system
  • Collect and analyze the reports
  • Decide which department will be involved in the disciplinary (decision making) process
  • Feedback the information (develop newsletter)
  • Develop and maintain the data collection system
Potential Obstacles: Having sufficient resources (e.g. people) to run the system, as well as having enough of the ‘right’ kind-of people, who are energetic, well-liked, well-known and respected in the company. Maintaining the energy required for the system to function.

5. Develop Reporting Form

It is important to have a reporting form that encourages accurate and complete reporting (e.g. questions that are understandable); otherwise reporters may provide erroneous or misleading responses. Determine:

  • What information you want to collect (e.g. only that information that will improve learning in the organization).
  • What you want to do with the information (e.g. case studies; summary data) as this will determine what information you collect.
  • What format you want to collect it in (e.g. electronic, paper or both).
  • What resources are required to develop the system (people, costs).
  • Whether (and how) the reporting form should be integrated with the current incident reporting system.
Potential Obstacles: It could be possible that too much /irrelevant data is collected. It is important that it is kept simple, but with enough detail that useful analysis can be applied to it.

6. Develop Template for Feedback to Potential Users


  • What type of information you want to disseminate (e.g. summary; case studies; “hotspots”; human factors data) • How to disseminate the information (e.g. newsletter)
  • Who will be involved (writing; editing newsletter; senior management endorsing action plan) • How often you will disseminate the feedback
  • Template style of the newsletter, title, etc
Potential Obstacles: The newsletter is not read. It may be necessary to find out what sort of information the audience would like to know about; provide examples that will be of interest and relevant to their job. One may need to vary the style over time, so that it maintains their attention, and so that they are likely to contribute to it.

7. Develop a Plan for Educating the Users and Implementing the System

Potential reporters must know about the reporting scheme and know how to submit a report; this will include induction courses; periodic retraining to remind staff of the importance of reporting; and ensuring that staff are provided with access to reporting forms. Below are some initial steps for implementing the system.

  • Develop brochures to explain the changes in the legal system
  • Present the changes to all staff
  • Train a “champion” (or a team) to be the main focus for the system
  • Explain to users how this new system will fit into the current system
  • Have a “Health and Safety Week” campaign to promote the reporting system
  • Include a section on the reporting system in the safety induction course
  • Use email and internet to communicate; announcing new information, and congratulating participants
  • Design posters to describe the reporting system process pictorially
Potential Obstacles: Information about the system may not be disseminated to a wide enough audience and to a deep enough level within the organization.

8. Developing and Maintaining the Right ‘Culture’

A number of additional issues concerning the ‘cultural’ aspects of reporting are necessary in order to maintain motivation to report, such as the trust between reporters and the managers must genuinely exist for the reporting system to work. The main aims are to develop an open culture in which people feel able to trust the system and to develop new ways to motivate people to use the system. Below are initial ideas.

  • System visibility – potential contributors to be made aware of the procedures and mechanisms that support the incident reporting system
  • Maintaining the employees’ voice – must ensure that the reports are used to voice the employees voice and not used to suit existing management priorities
  • Publicized participation – publish the contribution rate from different parts of the organization to show that others have trust in the system (but must ensure that this doesn’t have the opposite effect, such as asking for certain quotas of reports per month)
  • Develop ‘marketing strategies’ for enhancing safety culture (see Vecchio-Sadus and Griffiths, 2004): a) Customer centered – focusing the marketing strategy to suit the audience (e.g. management will have a different focus than the operations personnel); b) Link safety values to the core business – and show tangible evidence for their impact, such as how safety can enhance production, efficiency, communication and even cost benefits; c) Reward and recognition – positive reinforcement for reporting incidents
  • Change attitudes and behaviors - focus on the immediate, certain and positive consequences of reporting incidents and publicize the “pay-offs” of reporting incidents
  • Management commitment – raise awareness of management’s commitment to safety, with a “hands on approach”; have management involved in the reporting process to show that they visibly believe and promote the Just Culture
  • Employee involvement – ensure employee involvement so they are committed to the need to be actively involved in decision making and the problem solving process.
Potential Obstacles: It takes time and persistence to try and change safety attitudes and behaviors. Maintaining motivation of the personnel set with the task of improving safety reporting can be a potential obstacle.

Potential Obstacles:

Three planning aspects that need to be taken into consideration: 1) the required time to undertake the steps and sub-steps (include start and end dates); 2) the estimated costs involved and 3) who will undertake the work.

<<< continue reading—A Roadmap to a Just Culture, Case Studies >>>

Reprinted by permission from the Global Aviation Information Network.


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