Just culture: A case study of accountability relationship boundaries influence on safety in HIGH-consequence industries

In high-consequence industries the desire of many managers to “hold someone accountable” for errors remains a barrier to advancing meaningful safety agendas. The misconception that clear lines of accountability can and do exist, and that employees who cross the line between acceptable and unacceptable behavior should be punished, fails to recognize the different types of accountability relationships negotiated by employees every day. Such judgments run counter to the concept and practice of a just culture. Examination of the four types of accountability relationships, potentially seen within any just culture - hierarchical, legal, professional, and political, reveal the potential for the lines of accountability to frequently blur. This opaqueness is seen in numerous accidents which reveal the conflicting effects employees in high-consequence industries face as they move between and across these accountability boundaries. We use a case study, as a glimpse into the world of practice of aviation to illustrate the conflict, and double- binds, created as those in high-consequence industries negotiate the fluid lines of accountability relationship boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova Scotia, in 1998. Here we offer dialogue to aid in understanding the influence accountability relationships have on safety, and how employee behavioral expectations shift in accordance. We propose that this examination will help redefine accountability boundaries that support a just culture within dynamic high-consequence industries.