Sofema Aviation Services shares the following article written by Florin Necula, PhD, an Accountable Manager and Licensed Aircraft Engineer who combines academic insight with years of frontline operational experience.
In aviation, we like to believe that safety is controlled by regulations, procedures, training, audits and checklists. And to a large extent, it is. Aviation would not be safe without them.
But there is an uncomfortable truth: procedures do not apply themselves. People apply them. And people apply them inside a culture.
This is why the expression “safety culture” has become so common in aviation. It appears in safety management systems, audit reports, occurrence investigations, regulatory discussions and management meetings. Organisations are expected to promote it. Regulators expect to see evidence of it. Safety professionals try to measure it.
But what exactly are we measuring?
Can we really measure “the way we do things around here”? Or are we sometimes reducing a complex social reality to a survey score, a slogan or a slide in a safety meeting?
This article argues that safety culture is a real and important concept, but also one that is often oversimplified. Safety culture can be influenced, assessed and improved. But it cannot be fully captured by a single KPI, a checklist or a nice statement in a safety policy.
Culture is not created by posters
The word culture comes from the Latin cultura, meaning cultivation. That origin matters. Culture is not created by a poster, a policy or a management speech. It is cultivated over time – through what an organisation repeatedly accepts, rewards, ignores and punishes.
One of the classic early definitions of culture was proposed by Tylor (1871), who described culture as a “complex whole” including knowledge, belief, morals, law, customs and habits acquired by people as members of society. Although modern anthropology has moved well beyond Tylor’s original definition, the core message remains useful: culture is not one thing. It is a system of shared meanings and learned behaviours.
In organisational studies, Schein (1985, 2010) described culture as a pattern of shared basic assumptions learned by a group as it solves its problems and adapts to its environment. These assumptions are then taught to new members as the correct way to think, feel and behave.
This is highly relevant to aviation. A company may have procedures, manuals, reporting systems, risk registers, audit plans and training records. These are visible artefacts. It may also declare values such as “safety first”, “just culture”, “professionalism” and “continuous improvement”. But the real culture is often found deeper, in the assumptions people actually hold.
For example:
- “Reporting creates trouble.”
- “Delays are unacceptable.”
- “Good engineers do not ask too many questions.”
- “Paperwork is bureaucracy.”
- “Management says safety first, but production comes first.”
- “Stopping the job will not be supported.”
These assumptions may never appear in a manual. But they may control behaviour more strongly than the manual itself.
How culture is created
Culture is created when repeated behaviour becomes shared expectation.
People learn very quickly what is really expected in an organisation. They learn it from management reactions, supervisor behaviour, informal conversations, previous incidents, audit outcomes, customer pressure and the way mistakes are handled.
They learn the answers to questions such as:
- What happens if I report my own error?
- What happens if I challenge a senior person?
- What happens if I delay an aircraft for a technical reason?
- What happens if I admit fatigue?
- What happens if I refuse undocumented work?
- What happens if I say that the procedure is unclear or unrealistic?
The answers to these questions become organisational memory.
If people repeatedly see that reports are ignored or punished, silence becomes normal. If people repeatedly see that managers support technically correct decisions, trust becomes normal. If people repeatedly see that procedures matter only before an audit, compliance theatre becomes normal.
Culture is not what the organisation says once. Culture is what the organisation reinforces every day.
Why culture may be stronger than a procedure
Procedures are essential in aviation. No serious safety argument should minimise them. Aircraft maintenance depends on approved data, certification discipline, documentation, competence, tool control, independent inspections and regulatory compliance.
But a procedure only defines what should happen. Culture influences what actually happens.
A procedure may say: “All maintenance must be documented.”
The culture may say: “It was only a reset.”
A procedure may say: “Stop the job if unsure.”
The culture may say: “Good engineers solve problems, they do not create delays.”
A procedure may say: “Report fatigue.”
The culture may say: “Real professionals do not complain.”
A procedure may say: “Use current approved data.”
The culture may say: “We have done this many times.”
This is why culture can be more powerful than the procedure itself. Procedures establish formal expectations. Culture establishes practical expectations.
Reason (1997) argued that an effective safety culture includes a reporting culture, a just culture, a flexible culture and a learning culture. These are not created simply by writing procedures. A reporting system does not automatically create a reporting culture. It only provides the mechanism. Whether people use it honestly depends on whether they trust what will happen next.
In aviation, this distinction is critical. An organisation may have an SMS manual, a reporting tool, an audit programme and a risk register. But if frontline personnel believe that bad news is unwelcome, the system will not receive the information it needs.
The formal system may exist. The culture may still defeat it.
The birth of safety culture
The term safety culture became prominent after the 1986 Chernobyl nuclear accident. The International Nuclear Safety Advisory Group used the concept to explain that the accident could not be understood only through technical failures or operator errors. Organisational attitudes, management assumptions, authority relationships and decision-making patterns were also central (INSAG, 1986, 1991).
This was an important shift in safety thinking. It suggested that major accidents are not only technical events. They are also organisational and cultural events.
Accidents reveal not only what failed. They reveal what had become normal.
The concept later expanded into aviation and other high-risk industries. In aviation, safety culture became closely connected with safety management systems, just culture, occurrence reporting, human factors and organisational learning.
The UK Health and Safety Commission defined safety culture as the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the quality of, an organisation’s safety management (ACSNI, 1993). This definition remains useful because it links safety culture to both individual behaviour and organisational systems.
In aviation, almost every organisation claims that safety is a priority. But the real question is not whether safety is mentioned in the policy. The real question is: what happens when safety becomes inconvenient?
Safety culture in aviation maintenance
In aircraft maintenance, safety culture is not abstract. It is visible in daily behaviour.
It is visible when maintenance personnel use approved data even for familiar tasks.
It is visible when certifying staff refuse undocumented work.
It is visible when technicians stop the job because tooling, access, data, time or competence are not adequate.
It is visible when team leaders protect maintenance discipline under customer pressure.
It is visible when fatigue is discussed before it contributes to an error.
It is visible when investigations search for learning, not only someone to blame.
Aviation organisations operate in a demanding environment. Aircraft availability, customer expectations, night shifts, defect rectification, limited manpower, commercial pressure and operational disruption all influence decisions. A mature safety culture does not pretend these pressures do not exist. It makes them discussable and manageable.
A weak culture hides pressure until it appears as an event.
A mature culture brings pressure into the conversation before it becomes a hazard.
Personal culture also matters
Organisational culture is influenced by the people inside the organisation. Each individual brings personal assumptions shaped by family, national background, education, previous employers, professional identity and past experience with authority, blame and trust.
Hofstede (2001) showed that national cultures differ in areas such as power distance, uncertainty avoidance and individualism. In aviation, this matters because safety often depends on communication, challenge and speaking up.
A junior mechanic from a high power-distance background may be reluctant to challenge a senior engineer. A technician who previously worked in a punitive organisation may avoid reporting mistakes. A manager with a strong production-oriented background may unconsciously reward speed more than discipline.
Professional culture also plays a role. Aircraft maintenance engineers often value technical competence, independence, practical problem-solving and personal responsibility. These are strengths. But every strength has a shadow.
Confidence can become overconfidence.
Practical problem-solving can become informal workaround.
Experience can become “we have always done it this way.”
Commitment to the operation can become pressure to avoid delay at any cost.
A mature safety culture does not attack professional pride. It redirects it. The message is not: “Good engineers always find a way.” The message is: “Good engineers find the correct and approved way.”
Safety culture or safety climate?
One reason safety culture is difficult to measure is that organisations often confuse safety culture with safety climate.
Zohar (1980) introduced the concept of safety climate as employees’ shared perceptions of safety policies, procedures and practices. Guldenmund (2000) later reviewed the literature and described safety climate as the more visible and measurable expression of deeper safety culture.
In simple terms, safety climate is what people perceive now. Safety culture is deeper: what people have learned to believe is normal.
A survey may provide useful information about trust, communication, management commitment and reporting confidence. But it does not fully measure culture. Culture includes assumptions people may not even be fully aware of. It includes informal norms, stories, rituals, power relationships and operational compromises.
Cooper (2000) proposed a useful model in which safety culture includes psychological, behavioural and situational dimensions. This is practical for aviation. We should look not only at what people say, but also at what they do and what the organisation makes possible.
Therefore, safety culture should not be assessed through one method only. It should be understood through several sources of evidence, including:
- safety climate surveys;
- occurrence reporting behaviour;
- quality of investigations;
- effectiveness of corrective actions;
- audit findings and repeat findings;
- frontline interviews;
- management decisions under pressure;
- fatigue reports;
- training effectiveness;
- resource allocation;
- and evidence of organisational learning.
The important point is this: safety culture can be assessed, but it cannot be fully captured by a single number.
Can we really quantify safety culture?
Partially, yes. Completely, no.
We can measure indicators related to safety culture: reporting rates, survey results, audit findings, training completion, fatigue reports, investigation closure times, repeat findings and corrective action effectiveness.
But these are signals, not culture itself.
A high reporting rate may indicate trust. Or it may indicate increasing problems.
A low reporting rate may indicate good performance. Or it may indicate silence.
A good audit result may indicate compliance. Or it may indicate that the audit looked mainly at paperwork.
A positive survey score may indicate confidence. Or it may hide informal practices that people do not want to disclose.
This is why safety culture should not be reduced to a dashboard.
Safety culture is not a SPI. It is the context that gives meaning to SPIs.
Researchers and practitioners such as Anand (2024) have challenged the safety profession to think more deeply about the language, stories, rituals and assumptions that shape how organisations understand risk and accidents. This is important because safety culture is not a mechanical component that can be installed, calibrated or inspected in isolation. It is lived and reproduced through meaning, behaviour and social interaction.
Similarly, Dekker (2017) argues that safety should not be understood only as the absence of negative events, but also as the presence of capacities that allow people and organisations to adapt successfully. This perspective is useful in aircraft maintenance because safe performance often depends on judgement, coordination and adaptation within approved boundaries.
Measurement is useful. False certainty is dangerous.
A safety culture survey should start a conversation, not end it.
Can safety culture be changed?
Culture can be influenced, but it cannot be changed by decree.
A safety campaign may help. A training session may help. A revised procedure may help. But none of these alone changes culture.
Culture changes when people repeatedly experience that different behaviours are genuinely expected and supported.
- If management says “report openly” but reacts defensively to reports, the culture will not change.
- If management says “safety first” but only rewards aircraft availability, the culture will not change.
- If management says “just culture” but investigations still search mainly for someone to blame, the culture will not change.
- If management says “follow procedures” but procedures are unrealistic and no one improves them, the culture will not change.
Culture changes through consistency between words and actions.
In aviation maintenance, this consistency appears in everyday decisions: manpower planning, fatigue management, defect rectification, customer pressure, tooling, competence assessment, supervision, investigations, audits and management response to bad news.
Leadership is central, but leadership does not only mean senior management. Accountable managers, nominated persons, safety managers, compliance managers, station managers, certifying staff, team leaders and experienced technicians all shape culture.
In a maintenance organisation, one strong station manager or senior certifying staff member may influence local culture more than a corporate policy.
This is why safety culture must exist not only at headquarters, but at station level, on the night shift, during defect rectification, at handover and in the moment when someone decides whether to speak up or stay silent.
The danger of safety culture theatre
One of the greatest risks in modern aviation is safety culture theatre.
This happens when the organisation creates the appearance of safety culture without changing the deeper reality.
- The organisation has posters.
- The organisation has a safety policy.
- The organisation has a reporting system.
- The organisation has dashboards.
- The organisation has safety meetings.
- The organisation has training records.
- The organisation has audit evidence.
All of these may be useful. But none of them proves that a mature safety culture exists.
- A reporting system does not prove a reporting culture.
- A just culture policy does not prove fairness.
- A safety slogan does not prove safety commitment.
- A risk register does not prove risk awareness.
- An audit does not always prove operational reality.
- A training record does not always prove competence.
Safety culture theatre is dangerous because it creates confidence without necessarily creating understanding. It may encourage organisations to perform safety for regulators or customers rather than learn from operational reality.
A mature organisation should be willing to ask more uncomfortable questions:
- What are people afraid to report?
- Which procedures are followed only for audits?
- Where does commercial pressure influence technical judgement?
- What behaviours are rewarded informally?
- Which weak signals are repeatedly ignored?
- Do investigations create learning or only close corrective actions?
- Do frontline personnel believe management will support them when they make a technically correct but operationally inconvenient decision?
These are not signs of a poor safety culture. The willingness to ask them may actually be a sign of maturity.
A realistic view of safety culture
Safety culture should not be treated as a vague soft concept. It affects reporting, communication, compliance, fatigue management, competence, accountability and decision-making.
But it should also not be treated as something that can be fully engineered or measured through a simple tool. Culture is complex, dynamic and partly invisible.
A realistic view is that safety culture is both observable and interpretive. It can be seen in behaviour, but it also requires understanding meaning. It can be influenced by leadership, but not mechanically controlled. It can be measured through indicators, but not reduced to them.
Formal systems matter: SMS processes, reporting tools, investigations, audits, training, risk assessments and management reviews.
Informal systems matter too: trust, fairness, conversations, stories, professional pride, role modelling and management reactions under pressure.
The mistake is to believe that the formal system alone is enough.
Conclusion
Safety culture in aviation is real. But it is not simple.
It is not a poster.
It is not a survey score.
It is not a slogan.
It is not a paragraph in the safety policy.
It is the collective pattern of assumptions, behaviours and decisions that shapes how safety is understood and practised.
Procedures remain essential. Compliance remains mandatory. Training, audits and documentation remain fundamental. But procedures control work only when culture supports them.
Without the right culture, procedures become documents. With the right culture, procedures become behaviour.
Perhaps the most useful question is not: “Do we have a good safety culture?”. Every organisation has a culture.
The better question is: What does our organisation make normal?
- Does it make reporting normal?
- Does it make asking questions normal?
- Does it make stopping the job normal when safety is uncertain?
- Does it make learning normal after mistakes?
- Does it make fair accountability normal?
- Does it make compliance meaningful rather than bureaucratic?
- Does it make safety real when there is pressure?
Safety culture is not what is written on the wall. It is what people do when no one is watching — and especially when the organisation is under pressure.
That is why safety culture matters.
References
ACSNI. (1993). Organising for safety: Third report of the Advisory Committee on the Safety of Nuclear Installations Study Group on Human Factors. Health and Safety Commission.
Anand, N. (2024). Are we learning from accidents? A quandary, a question and a way forward. Novellus.
Cooper, M. D. (2000). Towards a model of safety culture. Safety Science, 36(2), 111–136.
Dekker, S. (2017). The safety anarchist: Relying on human expertise and innovation, reducing bureaucracy and compliance. Routledge.
Guldenmund, F. W. (2000). The nature of safety culture: A review of theory and research. Safety Science, 34(1–3), 215–257.
Hofstede, G. (2001). Culture’s consequences: Comparing values, behaviors, institutions and organizations across nations (2nd ed.). Sage.
Hudson, P. (2001). Safety management and safety culture: The long, hard and winding road. In W. Pearse, C. Gallagher, & L. Bluff (Eds.), Occupational health and safety management systems: Proceedings of the First National Conference.
Hudson, P. (2007). Implementing a safety culture in a major multi-national. Safety Science, 45(6), 697–722.
ICAO. (2018). Safety management manual (Doc 9859, 4th ed.). International Civil Aviation Organization.
INSAG. (1986). Summary report on the post-accident review meeting on the Chernobyl accident. International Atomic Energy Agency.
INSAG. (1991). Safety culture (Safety Series No. 75-INSAG-4). International Atomic Energy Agency.
Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.
Schein, E. H. (1985). Organizational culture and leadership. Jossey-Bass.
Schein, E. H. (2010). Organizational culture and leadership (4th ed.). Jossey-Bass.
Tylor, E. B. (1871). Primitive culture: Researches into the development of mythology, philosophy, religion, art, and custom. John Murray.
Wiegmann, D. A., Zhang, H., von Thaden, T., Sharma, G., & Mitchell, A. (2004). Safety culture: An integrative review. The International Journal of Aviation Psychology, 14(2), 117–134.
Zohar, D. (1980). Safety climate in industrial organizations: Theoretical and applied implications. Journal of Applied Psychology, 65(1), 96–102.
Tags:
Safety Culture, Safety Management Systems (SMS), Sofema Aviation Services (SAS), Aviation Safety Culture, Human Factors in Aviation, Sofema Aviation (SA), Aircraft Maintenance Safety, Just Culture Aviation, Safety Climate vs Safety Culture
