In my nearly 24 years as an aviation psychologist in the Royal Netherlands Air Force (RNLAF), I have seen first-hand the dynamics and complexity of the daily work situations of pilots and crew. I have also seen an organisation trying to enhance safety, prevent negative incidents and advocate the importance of learning. And I have seen this same organisation failing at all three. I became convinced that giving operators more discretionary space to use their expertise, developing a better understanding of successes and focussing on restorative instead of retributive justice are the keys to enhancing the safety and the effectiveness of the RNLAF. The RNLAF is currently transitioning to a Fifth Generation Air Force (5GAF). In order to stay relevant and gain the competitive advantage it needs, the RNLAF not only wants new weaponry but also a different management style that will foster different behaviour in employees. Specifically, the 5GAF focusses on trust, accountability, more freedom and space to employees and more room for self-organisation rather than top-down control. In my opinion, more discretionary space, a better understanding of successes and focussing on restorative justice would provide more competitive advantage than any weapons system we could acquire. Within the RNLAF context I studied the (in)ability to make sense of retrieved safety information and observations, how safety and effectiveness is achieved, and how this is hampered by safety beliefs and retributive response to undesired outcomes. My central research question is: How can we describe and enhance the safety and effectiveness of the RNLAF? The sub-questions all focus on understanding aspects of safety with the intention of enhancing it: Three key concepts are relevant to my research: safety culture, just culture and compliance vs. adaptation. These three concepts take up a significant part of the literature focused on enhancing safety and therefore, put together, they might provide a solid explanation for not only the safety an organisation achieves but also the stalemate and plateauing results an organisation meets when trying to further enhance safety. Safety culture, just culture and compliance are interrelated. Rules and procedures are regarded essential elements of a safety culture. The response to violating rules and procedures shows the just culture of an organisation. Safety culture, just culture and compliance provide a common thread in the safety documents of the Defence organisation appearing in the past six years. Documents show there is outside pressure to enhance the safety culture in the Defence organisation, an underdeveloped restorative just culture and a recognition that both compliance and proactive intervention (adaptation) are needed…

There is little empirical evidence on the predictive value of safety culture assessments (SCAs) in relation to how accident-prone an organisation might be. Recently, Antonsen not just demonstrated how a quantitative SCA mispredicted future safety outcomes, but actually showed an inverse relationship between the assessment and subsequent critical incident investigation findings. To add to our understanding, this article presents research on whether a SCA has a predictive capacity for safety outcomes. Like in Antonsen's research, an opportunity emerged when a helicopter taxiing accident, resulting in a rotor strike occurred for a helicopter squadron that had just undergone a SCA. The assessment used ‘culture ladder’ rubrics for its findings, which allowed us to look for specific features in the subsequent independent accident investigation (in which the researchers were not involved). As with Antonsen's findings, our research shows that a ‘ladder’-based assessment has little predictive value. Any predictive value it has is in the inverse of the assessment findings. For instance, where the SCA showed that the safety culture was very mature regarding finding a balance between safety and the mission at hand or the breaking of rules, the accident investigation pointed these out as the causes of the accident.