Just Culture


Sidney Dekker

"The reason why most people fail to report is not because they want to be dishonest. Nor because they are dishonest. The reason is that they fear the consequences, or have no faith that anything meaningful will be done with what they tell. And often with good reason." (p. 41)

"In fact, once a case goes to court, “truth” will likely be the first to suffer. The various parties may likely retreat into defensive positions from which they will offer only those accounts that offer them the greatest possible protection against the legal fallout." (p. 51)

"We assume that if an outcome is good, then the process leading up to it must have been good too-that people did a good job. The inverse is true too: we often conclude that people may not have done a good job when the outcome is bad." (p. 65)

"Lord Anthony Hidden, the Chairman of the investigation into the devastating Clapham Junction railway accident in England wrote, 'There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.'" (p. 66)

"The main question for a Just culture is not about matching consequences with outcome. It is this: did the assessments and actions of the professionals at the time make sense, given their knowledge, their goals, their attentional demands, their organizational context?" (p. 72)

"What matters in creating a Just culture is not to come up with a definition that leaves a number of supposedly sell-evident labels (“willful violation,” “negligence,” or people that are not “prudent,” or “normal,” or “reasonably skilled”) on the wrong side of the law and the rest on the right side. For those labels are far from self-evident." (p. 83)

"This is why a just culture should not give anybody the illusion that it is simply about drawing a line. Instead, it should give people clarity about who draws the line, and what rules, values, traditions, language and legitimacy this person uses." (p. 84)

"It is the whole point of legal proceedings to narrow in on a few acts by a few individuals or even a single individual. By its very nature, however, this clashes with what we know about accident causation in complex, dynamic systems today." (p. 97)

"To lay the basis for the emergence of a just culture in your profession or country, nothing is as important as starting at home, in your own organization. This will allow you to begin building relationships and trust between the first parties that matter: practitioners and their managers." (p. 137)

"Protecting your organizations data from outside probing should not be left to chance (…) and probably not just to cultural convention or political pressure either." (p. 140)


Andreas Mateou / Sofia Michaelides

"Two parallel investigations take place after every aviation accident: one technical, one judicial. The former must be conducted with the sole intention of making safety recommendations to prevent the recurrence of similar accidents." (back cover)

"Aviation safety is, to a large extent, built upon the trust placed by pilots, ATCOs and other aviation professionals in the process of accident investigation." (back cover)