Why a Just Culture May Be the Most Important Tool in Your Maintenance Organization’s Safety Toolbox
The Human Side of Maintenance Safety
Every Aviation Maintenance Technician (AMT) has experienced it.
A maintenance discrepancy is discovered after an aircraft returns to service. A task is completed incorrectly. A checklist item is missed. The immediate question by leaders is often: Who made the mistake?
While accountability remains critical in aviation, organizations that focus solely on finding the responsible individual miss a much larger opportunity to improve safety. Today’s most effective FAA Part 5 based Safety Management Systems (SMS) recognize that understanding why an error occurred is usually more valuable than simply determining who committed it.
This philosophy is known as Just Culture, and it has become a foundational element of modern aviation safety management. [1] Within a Just Culture, organizations strive to balance accountability with learning, creating an environment where employees can report hazards, mistakes, and near misses without fear of unfair punishment while still maintaining clear standards of professional conduct.
Culture Matters More Than We Think
Many organizations invest significant effort developing policies, procedures, manuals, and compliance programs. These tools are essential, yet every maintainer knows that written procedures alone do not drive behavior. When a situation happens in the field, how many are going to stop and try and find the exact policy that matches the dynamic situation? Many times, in these dynamic situations, the person calls upon their experience for a plan of action, washes that plan through the lens of the culture of the organization, and acts. Management expert Peter Drucker summarized it best:
“Culture eats policy for breakfast.”[2]
Organizational culture influences what employees do when supervisors are not present. It shapes whether technicians feel comfortable reporting an error or almost error , whether supervisors welcome concerns, and whether lessons learned are openly shared or quietly hidden.
A company’s culture is much like the personality of an individual. It affects every aspect of an organization and changes slowly because people naturally value stability and predictability. Every department within a company may have its own unique culture. There is value in recognizing and measuring what that culture actually is.
At Pacific Gas and Electric Aviation Services, I am asked to facilitate an outside Safety Culture survey. This provides key objective numbers and allows trends to appear and be tracked.
Reports as a Key Safety Indicator (KSI)
For maintenance organizations, culture becomes visible in everyday actions. When I report a near miss, does it come back to me in the form of more forms to fill out?
As the SMS Program Manager at PG&E, I do my best to “sprinkle sugar” on every part of the reporting process that I can. I always thank the submitter, for even the smallest report.
When AMTs share a positive experience when reporting and the following process, submitters feel heard, and the culture moves. I look for drops in reporting that cannot be accounted for by understood reasons (flight volume, etc.). Speed of report closure means nothing to me. Quality of report closure is how the front line knows that leaders are listening. Effective solutions often take the longest time to implement.
What Exactly Is a Just Culture?
Safety Management guru Dr. James Reason identified Just Culture as one component of a broader safety culture that includes: informed, reporting, learning, and flexible cultures.[3] Of all of these cultures, a Just Culture may be the most challenging to achieve, and easiest to get wrong. A Just Culture creates an atmosphere of trust where employees feel encouraged, and even rewarded, for sharing safety information while understanding where the boundaries of acceptable behavior exist.
Aviation Safety expert Sidney Dekker takes the concept further by challenging organizations to seek multiple perspectives rather than assuming a single version of events represents the complete truth. [4] A Just Culture accepts the value of multiple perspectives and uses them to encourage both accountability and learning.
For maintenance leaders, this means shifting investigations from “Who screwed up?” to more of a systems context of “Why did he/she fail”. Leaders, before acting on emotion, step back, take a breath, and ask “What made sense to the technician at the time?”, “What conditions existed?”, “Were procedures practical and understood?”, “Were resources adequate?”, and “What organizational factors influenced the decision?”
The result is often a deeper understanding of systemic vulnerabilities that might otherwise remain hidden. It is rarely ONLY about the individual. Just Culture expert David Marx summarized this objective well:
“Accountability must become compatible with system learning.”[5]
Defining the landscape – The Three Behaviors That Matter
One of the most practical aspects of Just Culture is its framework for understanding human behavior. It distinguishes between three categories: Human Error, At-Risk Behavior, and Reckless Behavior.
Human Error
Human beings make mistakes. They always will. Leaders HAVE to allow mistakes to be made.
Even highly trained technicians can unintentionally select the wrong part number, overlook a checklist item, or misread a maintenance reference. The rates of these inevitable human errors are captured by Dr. David Smith in his work Reliability Maintainability and Risk (2005).[6]
Just Culture starts with emphasizing the principle of “assume noble intent” and recognizing that human error can never be completely eliminated. Rather than punishment, the appropriate response is understanding how the system can be strengthened to prevent similar events in the future. When maintainers report honest mistakes without fear, organizations gain valuable information that can improve procedures, training, and workplace design.
At-Risk Behavior
At-risk behavior occurs when individuals drift away from established procedures without fully recognizing the associated risk. This is different than folks twisting their mustache thinking of diabolical ways to act.
Examples might include:
Performing familiar tasks from memory.
Skipping steps that seem unnecessary.
Using unofficial shortcuts that have become normalized.
These actions are typically not malicious. Often, they develop because employees are trying to improve efficiency or adapt to perceived operational pressures. The Just Culture response is coaching, education, and awareness rather than punishment. The goal is to help employees recognize risks they may not have fully appreciated.
Reckless Behavior
Reckless behavior is different, and in my experience, rare. This occurs when an individual consciously disregards substantial and unjustifiable risk, knowingly violating established standards or safety controls. In our regular SMS meetings, these are the rarest of reports or findings.
Examples can include:
Intentional falsification of maintenance records.
Deliberately bypassing required inspections.
Performing maintenance without proper authorization.
Unlike Human error and At-Risk behaviors which require leaders to console and coach respectively, Reckless may mean corrective or disciplinary action. This is because the behavior reflects a conscious choice rather than a mistake or misjudgment.
How do we separate the behaviors? – The “Line of Justice”
Many organizations spend considerable time trying to define the line between acceptable and unacceptable behavior. The line of justice separates reckless behavior from all other behavior.
The Just Culture perspective suggests it is more important WHO set this line of justice than where the line is set. So, who determines where the line is drawn? In my experience, it is crucial to have front line representatives involved to ensure that leaders do not confuse “work done” with “work imagined”.
Employees are far more likely to trust a system when behavioral expectations are clear, consistently applied, and developed with input from the workforce. Trust erodes quickly when similar events receive dramatically different responses depending on the employee involved. Consistency is essential.
A fair system builds credibility. A perceived unfair system encourages silence. Silence is one of aviation safety’s greatest threats.
Finding the Sweet Spot
A common misconception is that Just Culture means eliminating accountability. In reality, the goal is balance. On one extreme lies a blame-free culture where nobody is held accountable. On the other is a punitive culture where employees fear reporting problems. Neither supports long-term safety improvement. I like describing Just Culture like a warm blanket with a brick in it.
The ideal state is one where employees report hazards freely, leaders respond consistently, learning is prioritized, accountability remains intact. In addition, Organizational values need to be reinforced at every level.
What Leaders Can Do Today – If I tell you something, are you going to hit me over the head with it?
Just Culture is not implemented through a policy statement. It is built through thousands of daily interactions.
As the SMS Program Manager, I facilitate regular SMS Meetings with leadership. We structure the meeting to mirror the elements of the SMS of policy, Risk Assessment (design), Safety Assurance (Reporting and Audits), and Safety Promotion. The meeting is small to afford the feelings and emotions that can be generated by some of the reporting. We are all human, and I support leaderships reactions to some reports as it is normal. I feel that if this reaction was public, it may send the wrong messages.
Reports can remain open for as long as the leader (and/or myself) deems necessary. I stress that the quality of the closure is much more important than the speed of the closure. How each report is handled gives the submitter an accurate sense of leadership commitment, which is foundational to the culture.
I look at all reporting as a gift. Safety reports that may appear to be small in nature are celebrated by myself to leaders as it indicates that the front line feels comfortable talking to us. If they are willing to submit the small reports, we should feel confident we will get the bigger ones as well.
Leaders in all levels of an organization influence culture every time they respond to a reported error, conduct an investigation, recognize positive behavior, or discuss a safety concern. The actions taken following an event communicate organizational values more clearly than any written policy.
My favorite calls from leadership are the ones asking me “Hey, can you fill out a Safety Report about this event? I just found out about this.” or when leaders tell their folks “Thank you so much for telling me about that. Can you do me a favor and fill out a Safety Report about this so we can track it and make sure it gets visibility.” If you see your leaders saying these types of things, you have a very strong culture.
Organizations that want to strengthen their culture can focus on four principles:
- Encourage reporting without fear.
- Separate human error and at-risk from reckless conduct.
- Investigate systems, not individuals.
- Recognize employees who demonstrate strong safety behaviors. Celebrate the wins!
At the end of the day – What does all this mean?
There is a great Danish saying that states “Trust arrives on foot, but leaves on horseback.”[7] Culture changes slowly. Trust develops slowly. Organizations thrive when they understand that creating a Just Culture is not a program or initiative but is a constant reflection of leadership’s commitment to Safety.
Footnotes
- International Civil Aviation Organization (ICAO), Safety Management Manual (Doc 9859).
- Commonly attributed to Peter Drucker. The exact original source is not definitively documented.
- Reason, James. Managing the Risks of Organizational Accidents. Ashgate Publishing, 1997.
- Dekker, Sidney. Just Culture: Restoring Trust and Accountability in Your Organization, 4th Edition. CRC Press, 2024.
- Marx, David. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. Columbia University, 2001.
- Smith, David J. Reliability, Maintainability and Risk: Practical Methods for Engineers, 7th Edition. Butterworth-Heinemann, 2005.
- Traditional Danish proverb commonly used in trust and leadership literature.
Author Bio
Mike Kunkel is the SMS Program Manager for PG&E Aviation Services. He is an ATP-rated helicopter and airplane pilot with more than 30 years of aviation experience, including EMS, Part 135, Law Enforcement, and aviation safety leadership roles. He manages the Aviation Services Safety Management System (SMS), which includes the Aviation Safety Action Program (ASAP) and Flight Data Monitoring (FDM) programs. Additionally, Mike is an instructor on aviation safety at the USC Viterbi School of Engineering, Aviation Safety and Security Program.
