The term ‘no-blame culture’ flourished in the 1990s and still endures today. Compared to the largely punitive cultures that it sought to replace, it was clearly a step in the right direction. It acknowledged that a large proportion of unsafe acts were ‘honest errors’(the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators.
But the ‘no-blame’ concept had two serious weaknesses.
First, it ignored—or, at least, failed to confront—those individuals who wilfully (and often repeatedly) engaged in dangerous behaviours that most observers would recognise as being likely to increase the risk of a bad outcome.
Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts.
In my view, a safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behaviour and blameless unsafe acts. There will always be a grey area between these two extremes where the issue has to be decided on a case by case basis. This is where the guide-lines provided by A Roadmap to a Just Culture will be of great value. A number of aviation organisations have embarked upon this process, and the general indications are that only around 10 per cent of actions contributing to bad events are judged as culpable. In principle, at least, this means that the large majority of unsafe acts can be reported without fear of sanction. Once this crucial trust has been established, the organisation begins to have a reporting culture, something that provides the system with an accessible memory, which, in turn, is the essential underpinning to a learning culture. There will, of course, be setbacks along the way. But engineering a just culture is the all-important early step; so much else depends upon it.
James Reason