Today I am very pleased to meet Dr Claudio Noto*), airline pilot, economist, fellow at the Center for Aviation and Space Competence (CFAC) at the University of St. Gallen and a dear friend of mine. In this interview he shares with us some insights on how to structure processes and organisations to overcome the common tendency to demotivate exploration, learning and improvement. He explores with us the fundamental insights of what's called "just culture" - a term that describes a rethinking of social structures and justice that allows failure to become a springboard for one of our most important human strengths: learning, progress and innovation.
Thank you very much for taking the time for this "Human Facts meets". The last time we spoke was in our PLA podcast series with two other guests about the relevance of partnering leadership in technology heavy projects. And I promised that I would come back to you to explore this idea of 'just culture' in more depth - and here we are!
1. But before we delve into this promising topic, would you mind giving our readers an idea - perhaps with an example - of what's behind this term?
Claudio: A Just Culture can be described as an atmosphere
of trust that encourages - or even rewards - people to share safety-relevant
experiences, even if - or especially if - this includes admitting their own
mistakes or failures. This is how James Reason, a pioneering contemporary error
management researcher and arguably the godfather of Just Culture, defined the
term in 1997. According to Reason, learning comes from investigating the causes
of errors and then improving them. This mindset emerged from high-reliability
organisations (HROs), such as airlines or nuclear submarines, which cannot
afford to make the same mistake twice or allow simple mistakes to have
catastrophic consequences.
2. I am very convinced that as we move more and more into a networked world, where we can no longer trace cause and effect in a linear way, we need a different idea of how we judge and deal with failure. When was the first time you realized that being ashamed of failures and hiding them could make things worse?
Claudio: My first contact with Just Culture was during my
professional training as an airline pilot. In aviation, where we are constantly
concerned with reliability and where safety is our goal, the law requires us to
implement a Just Culture. Since then, I have seen that dealing with mistakes
transparently produces better results than hiding them. In particular, it
avoids the strange gut feeling that comes with shame and guilt, because by
admitting your failure you're ultimately taking responsibility by helping to
improve an undesirable outcome. It just feels good. Ultimately, it's about
acknowledging the long-standing insight that we, as human beings, are prone to
making mistakes, and punishment doesn't prevent mistakes from happening. In
fact, the opposite is true: stress
from shame or guilt over mistakes leads to more mistakes. So making
people feel bad is bad because it produces negative outcomes.
3. So let us know: What has been the most surprising and counter-intuitive observation for you so far, what has been possible to learn and improve because the 'punishment' or shame aspect of mistakes or failures has been removed?
Claudio: In general, I find it very relieving to be able to admit a mistake or a weakness, because then you can concentrate on getting better rather than on how to avoid to remain undiscovered. This not only increases personal comfort, but also reliability. Nowadays, pilots can be open about mistakes because it is accepted that it happens they happen. As a result, they routinely identify threats, anticipate errors and formulate mitigations to avoid adverse outcomes.
Similarly, if we look at our children, blame and punishment create frustration that leads to hiding mistakes and failures, but not to better results. Rather, they will just hide their chocolate and eat it in secret. So we encourage dishonesty because we don't give other - positive - choices. I suspect that's the opposite of what most parents intend. On the contrary, we should encourage children to accept their mistakes and find their own solutions, rather than blaming them for failure. In this respect, I have witnessed incredible learning potential, far beyond my own capabilities, when positive experiences such as this one were shared: This didn't work, what could you do better to get what you want? Of course, I admit that this is my ideal and that everyday life can be different.
4. I imagine there must be limits. We cannot tolerate every "failure" and let it go unpunished. Especially those that lead to death or the violation of human rights. So where do you draw the line? What are the areas where this just culture approach would do more harm than good?
Claudio: That's an important question. A just culture embodies strict limits. The very fact that mistakes and errors are unintentional makes them acceptable behavior. Who intentionally forgets their keys at home or deliberately burns their cake? Here, punishment doesn't make sense because it doesn't prevent mistakes from happening in the future. On the other hand, gross negligence or intent is not accepted. If unnecessary harm is accepted or even intended, then it is a person's behavior that needs to be addressed and not protected in a just culture.
This red line is key to the atmosphere of trust but, surprisingly, represents a frequent misunderstanding: A Just Culture is not a no-blame culture that just protects everyone from punishment and removes their responsibility. Rather, the culture is considered just in that it dissociates what we call honest mistakes from malevolence or gross negligence. Hence, the boundaries of a Just Culture are tied to the intent of the persons involved rather than the outcomes. It's a question of "Why did this happen?" rather than "Who did this?". For that matter, I cannot imagine how to associate the impairment of human rights with honest mistakes.
5. Coming back to the benefits of this way of thinking. Where and how do you think - or have you already observed - this idea of just culture could best be incorporated into organizations? Specific processes to be redesigned, specific industries that could benefit, or specific professions?
Claudio: When we look at industries that involve complex systems with high failure probabilities, we should recognize that effective failure management is the key and only way to achieve reliability and resilience. A Just Culture is therefore a promising approach to success for all organizations where avoiding failure at all costs effectively inhibits innovation. However, I fully acknowledge that our common attitudes of shame and guilt are difficult to overcome because many of us have been socialised with blame and punishment and are often blinded by short-term goals.
6. And what are the implications for how we need to rethink performance management and how we measure performance, particularly individual performance?
Claudio: The fundamental mindset shift is to stop pointing fingers and blaming individuals for their errors and mistakes that happen unintentionally. Instead, we need to appreciate the contribution of unintentional sub-optimal results to the learning process: how to do it better next time and become more resilient and reliable.
Many readers will certainly be familiar with the saying: Admit nothing, deny everything, blame others. Although some may even have experienced that it seems to work, the success rate of this strategy is at best marginal and short-lived. It is also not scalable to entire organizations or systems.
The contrary is a citation that is commonly attributed to Thomas Edison: I have not failed. I just found 10'000 ways that don't work. This nicely illustrates how an organization can embrace failure to advance.
7. So if any of our readers here would like to introduce this approach into their organisations, what would you say might be good areas to start experimenting with? What are the do's and don'ts to consider?
Claudio: First of all, accept that admitting mistakes does not seem to be a key human skill - at least not in our current socialisation with blame and guilt. A proper approach to error management therefore depends crucially on getting everyone involved and creating an atmosphere of trust. Stop asking "who" and start asking "why".
In 2017, Sydney Dekker described a just culture as one of trust, learning and
responsibility: 'In my view, it is the responsibility of an organisation to
create an atmosphere of trust, and the responsibility of employees to
reciprocate that trust by sharing their experiences to foster a continuous
learning process.
However, trust is not something that can be asked for; it has to be earned. In the beginning, this may be
the hardest part, because it means first admitting your own mistakes and
failures. And when you admit to your complacency that your door is
always open, be aware that you never know who won't come knocking or who won't
rely on you.
8. What do you think personally? In 50 years, when we look back on what we are discussing today, what do you think we will say about this small root of rethinking the foundations of our structure and society?
Claudio: I hope that we have made progress in learning to focus on how to do things better, rather than on the fact that things went wrong. That would make us more resilient as a society, and perhaps better able to work together to tackle the challenges that lie ahead on a global scale.
9. Human Facts collects from every interview partner questions that had the power to change your live or your thinking. What is the question that you’ve been asked that changed your life?
Claudio: It's always the same simple but powerful question: When I find myself in the middle of various challenges I have taken on, the most striking thing is when someone asks: Why are you doing this? If I can't give myself an honest answer, then I know it's time to start making changes, even small changes. I think it's that simple. But beware: I find myself failing at this principle more often than succeeding!
Thank you very much for your time, Claudio, for helping us so generously to rethink how we should think about mistakes and failures. I want your insights to be shared and discussed beyond the boundaries of aviation, and I am the first to support that. I am so grateful that our paths have crossed and that your insights are helping me to broaden my horizons in terms of organisational design. And I'm grateful that you plan to join our Partnering Corporations Think Tank, where we will initiate an informed dialogue on how we design processes and organisations from a partnering perspective.
I first met Claudio at the University of St. Gallen in in 2010 as a volunteer coach for the coaching program for first-year students. We worked together as assessors for the students during the annual Development Centre Days organized for the students. I was fascinated by his very empathetic, yet to the point way of giving feedback to the students. He left them with no need to defend themselves, but with an idea and motivation not to give up on developing their potential. I wondered if he was a professional coach, but instead learned that he was an airline pilot, and that in aviation, giving and receiving feedback in a useful way is critical to keeping us all safe. Since then, we have maintained a close, infrequent, inspirational exchange between our different disciplines, celebrating our love of Italian food and wine, and our love of outdoor activities in the St. Gallen region.
*) Background of Dr. Claudio Noto: Claudio is Airline Pilot, Economist, and a Fellow at the Center for Aviation and Space Competence (CFAC) at University of St. Gallen. In this role he currently researches the economics of regional airports and the topic of just culture from a corporate perspective, thereby supporting academic studies and providing expert advice to the industry. After obtaining his MA in Economics at the University of Zurich and his PhD in Management at the University of St. Gallen, Claudio (co-)authored several economic publications. His dissertation on airport capacity allocation with network airlines was awarded the German Aviation Research Society's annual Prize in European Aviation Economics and Management. His main occupation is as a pilot for an international airline, and he is an experienced flight instructor and a coach.
