With 35,000 flights a day and not a single commercial aircraft accident in 2017, we could all learn thing or two about safety from Europe’s air traffic management industry.
Aaron Curtis, an air traffic controller since 1999 and based at NATS in Swanwick, Hampshire, talked to health and safety reps in the electricity supply industry about why a Just Culture in aviation contributes to this safety record.
After decades of innovation in systems, technologies, procedures and safety management systems, improving safety in modern day industries relies on a good safety culture.
The single most important part of a good safety culture has been recognised as Just Culture. This is an atmosphere of trust where employees feel naturally able to call to attention safety risks – even when they themselves may be implicated in the discovery of that safety risk.
Just Culture became a legal requirement in aviation in 2014 via a European regulation on occurrence reporting. It defines Just Culture as:
“…a culture in which front line operators or other persons are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated.”
The first step in instituting Just Culture is to build trust between organisational stakeholders.
To develop this trust, all relevant stakeholders should be engaged and participate in creating and implementing a Just Culture policy. The views of the reporting community are especially important, as they provide the information for safety improvements.
Aaron said: “It takes hard work and effort to change the culture of a company. It has to stem right from the top or it won’t work.”
And organisations have to continually work on their Just Culture, especially as it evolves.
Safety critical industries rely on constant and constructive information to validate the safety of their systems and procedures. A key element of this validation comes from staff input.
Individuals will only report errors, particularly where blame or fault may traditionally be attributed, if they are treated fairly and justly.
With this data, organisations can investigate safety events and put measures in place to prevent repeat occurrences.
Aaron said organisations get better reports if an independent safety department conducts the investigation rather than the department where the incident happened.
He talked about the “Swiss cheese model” of accident causation which illustrates that, although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur.
The key point was “to learn about the holes so we can plug them – but getting people to tell you where the holes are is a challenge. That’s why it’s so important to get reports,” he said.
But he warned that sanctions that don’t fit the crime or management failure to understand the mood of the staff destroy a Just Culture.
Route to a Just Culture
Aaron’s slides provided a useful map for any organisation that wants to introduce a Just Culture:
Commitment of staff at all levels
- fair and reasonable
- shared performance goals with a specific timeline
- encourage discussions about safety
- reward and encourage
- involve staff in creating a Just Culture policy
- encourage good behaviour
- support and protection
- practical procedures
- active support from the top
- endorsed by the staff
Protection of data
- communicate the company’s policy
- access only for authorised personnel
Protection of people
- de-identify the reporter and the reported
- reinstatement in the workplace
- organisational support
- staff can count on the organisation to provide legal support if needed
- agree scope of legal support
Drawing the line (interpreting human performance)
- agreement on the process with staff
- involve staff reps in the application of the process
- one size does not fit all
- interpretation of human performance, independent from line management
- appropriate expertise
- guarantee of consistent implementation of the Just Culture throughout the organisation
- to win the trust of all staff that fair and just judgements will be made
- initial, continuous and conversion training
- develop guidelines for reporting
- crisis plan
- ad-hoc courses if the need is identified
- intranet, awareness days, posters, publicity
- communicate about specific cases
- foster voluntary reporting
- share the analysis
- provide feedback.
- air traffic management in other countries.
Just Culture Toolbox, written by the air traffic management partners for Just Culture, has lots of ideas on best practice
Video: Human factors and system safety – Professor Sidney Dekker explains Just Culture: why you need it, what it is, and how you get it.
Heinrich’s Accident Triangle explained