THE HUMAN ERROR
A Just Culture – The Foundation of Any Successful Safety Management System
By Gordon Dupont, System Safety Services
Was it cement boots for Joe? Let’s look at some of the cultures that can be found in our industry.
ANY EMPLOYEE WHO THROUGH THEIR CARELESSNESS CAUSES AN ACCIDENT, INJURY OR DAMAGE IN EXCESS OF $1,000 WILL BE TERMINATED
THE ERA OF THE “BLAME” CULTURE. This culture has been common throughout history. It is based on the “eye for an eye” way of thinking. It is seen to be doing something about the problem. It seems to “solve” the problem, as the instigator of the problem is no longer there to do it again. It does not determine or solve the root causes of the problem.
E
very industry has its own culture and aviation is no diff erent. Our industry is known as being unforgiving for any human errors made, especially if the error involved damage to an aircraft. Giselle
Richardson, a close psychologist friend of mine, was the keynote speaker at our fi rst conference on maintenance errors and their prevention in 1995. One thing she said that has stuck in my mind to this day was: “Only the mafi a with their cement boots has a harsher discipline policy (than aviation)”. Thinking on my many years in aviation, she was right. I can recall going to work one day and asking where Joe was. It turns out he was fi red on my days off and not one person knew why. It was later rumored that he had left his fl ashlight up behind the instrument panel which later had fallen out on the captain’s foot during pushback from the gate, resulting in a delay.
It causes people to try to hide their errors. It creates a lose-lose situation and will doom an SMS to failure.
IT DEPENDS UPON THE CIRCUMSTANCES
THE ERA OF THE “IT DEPENDS” CULTURE No one knows what will happen when an error is made. It could depend on the mood of the boss that day. It likely will depend on how expensive the error is and how much media attention it gets. It fails to determine the root causes and results in an “it wasn’t me” culture, much like the blame culture. It is a lose-lose situation and will also doom an SMS to failure.
Ther EXPERIENCE BEYOND
e’s Dedication, Resourcefulness & Honesty You Need Them All For A Reliable
PARTS Source
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