Just Culture

[Wg Cdr Spry]

Chaps, we're all being encouraged to submit reports under the umbrella of a "Just Culture", but a conversation I had at the recent FSO symposium made me wonder if we really believe we're living in such a healthy environment. I believe we are, but if there are any doubters out there, I'd be interested to canvass your opinions - remember, we're also a Learning Culture, so we should listen to people's concerns....over to you

Yours aye

Spry

[AtomKraft]

'Just culture' my arse.

I suggest we rename it 'Where there's blame, there's a claim'.

[Just This Once...]

The Just Culture depends on the agenda of the day. If the message can be shaped or used to support something that the wider chain can support then Just Culture works. If the message or event is deeply uncomfortable for someone in the higher echelons then the retribution can be brutal, even if someone is expressing an airworthiness concern.

I have known people to removed from post within a day for speaking out with a genuine concern, even if that person has documented and referenced all the supporting evidence.

It can be brutal at times if someone highlights something that can embarrass a star ranking officer.

[fabs]

I think it is branch dependant (in the RAF anyway). I am impressed with the number of reports submitted by my stn's aircrew and feel that amongst those there is a real sense of 'just culture'. Compare that to my branch (ATC) where we are still stuck in the dark ages, personnel are genuinely concerned that if they make a genuine mistake the whole world will come down upon them.
No amount of mouth music from Cmd changes the fact that they do come down on people like a ton of bricks; or they come down on the LEO/SATCO who dares to stand up for their man by threatening to pull Examining Quals.

Interestingly (or not) I wonder what opinions are on the UK Airprox Board, you know that group of people that 'do not apportion blame'. Yet take a cursory look at any of the blue books and in the reports you'll see sentences like 'although the controller was not mandated to blah blah under a BS he has a duty of care' and 'some board members suggest that the airmanship displayed by the pilot was .....'

We've got no chance of a truly just culture until everyone is on board and singing from the same hymn sheet. Just because Air Command and MAA say we have a 'just culture' doesn't mean one actually exists.

That said, it is getting better, slowly.

[VinRouge]

Just culture can exist, but can sometimes only exist as long as the posting cycle in the command chain.

There are some real megalomaniacal very senior officers out there (star rank) who are hellbent on perception as opposed the right decision. Perception gets you promoted, doing the right thing doesn't.


How many senior officer shriv and pjhq table top exercises include command decisions based upon supervision, authorisation and flight safety? I don't know, but I bet all are designed around moulding commanders to be op focussed rather than make balanced risk decisions. At how many table tops have individuals turned around and said "we aren't launching for a low priority mission as I have supervisory concerns?"


What is going to get a senior officer promoted? Performing under a situation of complete lack of resource, pushing the limits, perhaps bleeding his guys dry, or someone who speaks out and says we don't have enough to complete the task?

If the RAF very very senior hierarchy is serious about just culture, they need to make a serious statement and carry out very public actions to demonstrate their devotion and understanding of just culture. Such as sacking anyone who blatantly goes out their way to put their career ahead of just culture. star rank included.

There is a lot of learned helplessness out there too. People are reporting, but things are still getting worse, with lots of paperwork being generated, deck chairs on the titanic being shuffled, but nothing changing. Documenting risks on a psrr will not stop an accident. Spending some of that 2 billion cost underspend on risk mitigation will do however.

But seeing as the solution is

More people (not talking about numbers on books I'm talking about trained and experienced personnel here coming up with the goods)

More downroute spares and tooling/role support

Better training

Regulation based upon common sense and best practice, not the exceptional op requirement which has resulted from decades of cuts. How many 'short term' changes to regulation to meet a particular short term requirement are still there? 130 hours in a month springs to mind.....

Which involves spending money, I think we know we had better get used to rearranging chairs on the titanic. :ok:

[MAD Boom]

Having experienced this 'Just Culture' from the wrong side I say no, we are not there yet.

Submitting reports cannot solve problems on their own, to create a culture we need fair and just treatment of individuals following unintentional acts and errors. Reputation and outside perceptions are rather large barriers at present and I would like to see a little more loyalty and backbone from our upper levels who sometimes value their own careers more highly than the success of the system.

Just because we say we have a Just Culture doesn't mean one actually exists

Agreed, Sir. Actions speak louder than words.

[Just This Once...]

Given the huge changes in recent times with the DH construct it may be helpful to keep this thread for those still serving and perhaps those who have left in the last year or so. Those of us who still serve can still remember what it was like 25, 20, 15, 10 years ago if any comparisons are needed.

[Fox3WheresMyBanana]

The purpose of introducing a "just culture" is not to promote change, but to cover the arses of the politicians when they make changes which will do the opposite of promoting justice, e.g. only approving the promotion of VSOs who say "Yes Sir, and that won't affect our capability Sir" to every proposed budget cut.
One look at every other branch of the Government will tell you that.

The only solution is to elect MPs who actually have moral, just values. Good luck with that - and that grass isn't any greener outside the UK.

[dervish]

If the message or event is deeply uncomfortable for someone in the higher echelons then the retribution can be brutal, even if someone is expressing an airworthiness concern.


Spot On.

This site

https://sites.google.com/site/militaryairworthiness/


has published the evidence and named the DE&S secretariat at Abbey Wood who continues to brief against people who express airworthiness concerns. Will Wg Cdr Spry care to comment?

[Wrathmonk]

Do you still have that supposedly 'anonymous' form for submitting Flight Safety incidents that you have either committed or seen committed? The one where you had to put your name, rank and contact details on the bottom "just in case IFS [as was] staff needed to contact you to discuss your submission".

The gp capt at IFS was most put out when I suggested that the line "these contact details will only be used by IFS staff" should be added to those other standard phrases "The cheque is in the post", "Don't worry, MT will pick you up" and anything told to you by your desk officer ;)

[Biggus]

Wg Cdr Spry,

I think you've got your answer.........


.... perhaps your "belief" isn't justified by the reality on the shop floor?

[downsizer]

No just culture here, just finger pointing and @rse covering.

[VinRouge]

The message I think a few senior officers seem to have forgotten is that self regulation is a priveledge and not a right.

Next big accident will prove that.

[obnoxio f*ckwit]

I once told my Stn Cdr to his face during my ACR debrief that I didn't believe him when he told me the RAF had a "just culture" ( it was the mid 90s so not sure if the actual phrase "Just Culture" had been invented but that's what he was talking about), he took it rather well to be honest.

There had been a recent incident where someone had indeed been f*cked over by the system, including that Stn Cdr, and I merely pointed out that "the system" can talk the talk all it likes, but all that can be undone by a single poor decision, and that there was just such an undercurrent among the JO aircrew on his Stn. The actual incident was never mentioned, but he knew what I meant.

Still surprised I got away with being quite so blunt.

[Tiger_mate]

A cynic would argue that the 'Just culture' policy is a buffer zone between Haddon Cave and the MoD to provide an Early Warning System to the corridors of power of impending Risk of litigation. Otherwise known as a*** covering smoke and mirrors.

However the difference in overall Flight Safety data between today and pre millennium is most impressive, so something is working.

[MG]

It's a while since I flew, but about 6 years ago I felt the need to submit a CONDOR. Whilst my name didn't (seem) to get to the stn cdr of the place concerned, my rank and 'experience level', shall I say, certainly was known. Tie those together and you get a very small pool of suspects. I trusted that system as I truly believed that it was there for all the right reasons, but I certainly felt let down and exposed.

I hope things are better.

[just another jocky]

I agree with several comments made here.

I think the system is really trying to encourage a Just Culture on the front-line (ie flying) but as has been said, it can all so easily be undone by one decision from a higher rank, possibly even a benign one but one that is not explained correctly or is mis-perceived by the wider audience.

Is the safety system better than it was 20 or 30 years ago? Undoubtedly. Is it being misused by individuals to cover a**e, I don't know. The cynic in me believes possibly, the FSO in me hopes no.

I have seen some very positive benefits at my Stn from the revision of RAF FS, and for me as a pilot, that's what I want.

[Hathwolves]

This takes me back a few years now where we had an incident occur on the ground during servicing. The report went in (can never remember the actual name of it!), where our line management all the way up to SENGO was covering us and not apportioning blame.
When the incident was covered in the magazine, our OC Eng at the time, screwed us over, placing all blame on us rather than the system. This is after we had been promised top cover on the station. It definitely affected a lot of the lads on shift, as they didn't feel comfortable reporting on any issues because of the **** storm that rolled down onto us all.

[Le chat de factoire]

I owned up to a mistake I made got thanked for my honesty 2 months later received a letter about my error threatening me with dismissal,incorrect procedure followed by higher management,on this day in question Jengo made some mistakes also I was told it does not matter he is posted.Don,t talk to me about a just culture until aircrew and higher management receive the same training as groundcrew, learn from mistakes and not cover them up.I have evidence of this but not going to discuss on open forum.

[oldgrubber]

One of the problems with the "Just Culture" as I have witnessed it, is the opposite of what many are posting here.
As a 33 year time served engineer I saw many occasions where a person had negligently worked outside of a laid down procedure or practice and received nothing more than a "don't do it again" or "write a Cockpit article".
The fear that they will "lawyer up" and potentially uncover unit managerial failings during the process often causes a "soft" approach.
I still believe that removing someone's supervisory status for "re-education" works wonders to focus the attention, or giving a lad monthly QM checks should happen to make him realise he needs to do better.
Troop the buggers once in a while, if the procedure is in the book and they willfully ignore it, they are breaking the rules and need to be told so.

Cheers

[Flying Rhino]

Just culture is very difficult, as drawing the line between what is acceptable and not whilst still encouraging reporting is hard. The one really positive thing that DAEMS has done is train people to investigate and sit on ORGs. There are now lots of different ways to report but by far the most transparent is ASIMS and all should be encouraged to use it. The idea of 4 worlds does concern me as it almost confirms the traditional widely perceived pecking order of aircrew first and others at the bottom. Surely we should all be in the same world; Aviation.

A just culture is not just dependant on the command chain accepting errors as part of normal business; people have always made mistakes and will continue to do so it is deciding if you want to know about it. All the individuals who make the errors must also have the moral courage to accept that they will probably be criticised when they report and it is investigated. If you file a report and it is first order ie I made a mistake you must expect OMs etc to comment and look for ways in which to prevent it happening again. The dented personnal pride needs to be forgotten if it prevents the same occurence happening again; often the difference between being able to report it on ASIMS and a smoking hole is luck.

Trying to break norms is also difficult especially when it is perceived that this is the only way we can get the job done. This is where there needs to be some moral courage amongst our leaders to listen to the concerns and make a decison which will invariably reduce output.

One thing that is frustrating post Haddon-Cave that he told us not to do is continual change which is something the miltary cannot resist. We are always changing the name of things eg RAF Flight Safety. We now appear to be a jungle of regulation; more and more we appear to have to refer to a CAP rather than an RA to find guidance. Can we have some more regulation for ATC as they are not completely swamped yet but it is close!

[ExAscoteer]

It's a while since I flew, but about 6 years ago I felt the need to submit a CONDOR. Whilst my name didn't (seem) to get to the stn cdr of the place concerned, my rank and 'experience level', shall I say, certainly was known. Tie those togehter and you get a very small pool of suspects. I trusted that system as I truly believed that it was there for all the right reasons, but I certainly felt let down and exposed.

I hope things are better.

A very similar thing happened to me.

I CONDORed a Senior Officer and got hauled through the mire as a result. That was a major factor in my taking my option and leaving the Service.

Just Culture my arse. The Service has never shown loyalty towards towards those percieved to be 'rocking the boat'.

[alf5071h]

The concept of a just culture is one of those unattainable ideals, which represent the gap between theory and practice.
A just culture is not something you have; it’s like safety, it’s something you do.
Similarly, definitions of what should be done are not a great help, particularly where the managing individuals hold the definition, and where judgement is always with hindsight. Drawing a line is not important; it’s who draws the line (Dekker).

The key issue is not the submission of reports, but how they are handled by individuals. Will those who manage be free from bias; do they have and apply sufficient human factors knowledge in their judgements, do they have sufficient role and situation experience – including that of ‘error’.
Do the operators at the sharp-end have similar qualifications so that they can draw their own line, but in this instance in real time.

If the sharp-end can be provided with the means of ‘doing the right thing’ for the situation, context, and within the limits of human performance, then there should not be any need to judge individual performance after the fact. However, situations and human performance are never clear-cut, thus the managerial judgement must have similar provisions for ‘doing the right thing’.
This requires training and knowledge in the skills of human performance, primarily for the blunt-end, because if the sharp-end activities result in ‘crossing a line’, then it’s more than likely that management have accountability for ‘the line’ and many of the situational contributions to human performance.

Management should consider that there is no such thing as error. (http://csel.eng.ohio-state.edu/woods/error/app_cog_hand_chap.pdf) Instead substitute ‘variable human performance’ which might trigger an alternative way of thinking about people and safety in general. Then perhaps we won’t need to ‘create’ the concept of a just culture; instead use a new way of thinking about safety.

For staff college reading The ETTO Principle. (www.hfes-europe.org/books/proceedings2012/Hollnagel.pdf)
and
“… we must all be held accountable for our efforts to make the system safer”
. (www.safer.healthcare.ucla.edu/safer/archive/ahrq/FinalPrimerDoc.pdf )

[22/7 Master]

You must cut the process. Join up MAA inspections, standards visits, engineering QA, Command assurance visits....make the burden on the units less erksome.

It is a major factor in Morale being at rock bottom, along with remuneration being 20% less than 3 years ago, SDSR and NEM on the horizon and senior officers transferring pension wealth from juniors under the term 'transition arrangements'. Its no longer a way of life, its a mediocrely paid job with barely minimum wage for the hours we work and the responsibility we are asked to hold.

But I bet the process monkeys in our ivory towers click the score card 'green'.

So to answer the question, make half your Air Safety staff redundant, then we can actually get on with our real job. We at the coal face are not idiots, stop assuming otherwise and maybe we can start to regain this roadsmash of a system.

Rant over, Sir.

[Bismark]

What an interesting response from who I presume are RAF posters. In my experience the Fleet Air Arm have successfully operated a just culture for decades. The principle of allocate blame where it is honestly due and then move on, but more importantly learn from errors and encourage honest debriefing is a watchword in the FAA. It was never more stark than the difference between a FAA BOI and an RAF one. The former was independent and reported in weeks, whereas the latter could take years and was often manipulated up the command chain......did anyone mention chinook.

[Lima Juliet]

I really can't see how DAEMS is going to work...

- No trust in 'Just Culture'
- No time to submit reports
- Inviting outsiders to conduct OSIs will be frowned upon by Stn Execs

I hope I'm wrong!

LJ

[high spirits]

Ahhh, got those rose tinted specs on again shippers.....

[Laarbruch72]

The concept of a just culture is one of those unattainable ideals


Not in most European airlines, it works perfectly well and pilots can stay truly anonymous if they want to. The management genuinely respect it too. Were you referring to just culture as a military ideal?

[MG]

Having submitted my last post, I do believe that we (RAF) want a Just Culture and that we achieve that at Sqn level and, mostly, higher. I just think that the system is open to those who want to abuse it, usually through ringing up mates and having 'off the record' chats to find out things that they shouldn't. I suspect that was what happened in my earlier example.
So, in response to Bismark, I suspect that the RAF is no better, nor any worse than the RN.

[PARALLEL TRACK]

Is a Just Culture really a topic for the RAF Flight Safety Team to discuss on an open forum? It has already become a 'bitch feast'! Come on Wg Cdr Spry you must have thought this one through before you submitted your post. Oh I guess not. Did you really think you would get a big pat on the back from the Gp Capt for this? Get back to your real job and stop wasting time!!!!!!!!!!

[MG]

Is a Just Culture really a topic for the RAF Flight Safety Team to discuss on an open forum? It has already become a 'bitch feast'! Come on Wg Cdr Spry you must have thought this one through before you submitted your post. Oh I guess not. Did you really think you would get a big pat on the back from the Gp Capt for this? Get back to your real job and stop wasting time!!!!!!!!!!
Very unfair!
I don't think this thread is a bitchfest (yet) and I do think it can contribute to an informed opinion. What better way than to engage with the forum that people often turn to to vent their spleen?

[Just This Once...]

Is a Just Culture really a topic for the RAF Flight Safety Team to discuss on an open forum?

By its very nature, if it cannot be discussed on an open forum then it must have failed. There are some candid comments on here and nothing that can be regarded as a 'bitch-feast'.

[dervish]

Since finally retiring I’ve taken a keen interest in two cases I think unjust, the Chinook and Sea King ASaC crashes. In both cases MoD continues to unjustly apportion blame. MoD support retired officers who publicly blame the Chinook pilots in the media. On Sea King, MoD openly blame a civilian for what they have determined was the most likely of the 3 contributory factors listed by the Board of Inquiry. (I’ve deliberately used “MoD”, not RAF or RN. The Army isn't blameless either.) In each case senior staff were allowed to judge their own case and evidence that would have “cleared” these people withheld from inquiries. I wish I knew more but the published evidence is very clear and it doesn’t indicate a just culture. If Wg Cdr doesn’t know this then he’s not doing his job. If he does, the original post is just a bloody wind up.

[SteveTonks]

Having completed my previous tour in the the newly form Duty Holder construct I can recognise many of the issues previously posted.

A Just Culture is very difficult to achieve, it is a question of proportionality and pragmatism. I can remember a number of cases that we had to advise the hierarchy as to what would be acceptable in the form of punishment, if any at all.

The Just Culture principle is taken very seriously within my specific area and whilst there is scepticism from the coal face the message is leaking through to others at my level.

The DAEMS system was devised to provide an independent investigation and audit facility for the just culture and links the fair and just model used by FS at a stn level to apportion any blame. I can vouch for the depth of these investigations as the buck doesn't just stop, the entire system is investigated and reported upon.

There are still issues that need to be addressed however. There are (albeit a minority) now in senior management that are destroying the shaky belief in Just Culture. This is frustrating because once confidence is broken it is difficult, if almost impossible to rebuild. The next one is that the process is too slow. A large stn like Brize can receive hundreds of DASORs a week, from the very trivial to Cat 1 AIRPROXs. There just aren't enough people in Air Safety to process all of these in a timely manner. One notable DAEMS investigation took over 6 months to conclude, leaving the individual concerned in limbo and the stn hierarchy floundering for a suitable course of action. The last one is access to ASIMS. Having ASIMS on the intranet is fine but for those deployed or just down route it would be far simpler to have a secure gateway to access ASIMS via the internet. Changes should be made to the form also to speed up the input but a broader discussion is needed on that.

Overall the system is there and working, those who comment that Air Safety staff need to be reduced really have no clue what it trying to be achieved. The Haddon Cave report was damning of the MoD and the culture that existed at the time. The world has changed and Crown Immunity from corporate manslaughter charges just doesn't exist. These very same Air Safety staff that need to be culled are there to provide the evidence to back up the Sqn/Stn Cdrs and the higher echelons when their decisions are called into question. The job needs to be done correctly without prejudice to Air Safety and if something or someone is compromising this then action needs to be taken, brushing stuff under the carpet is no longer acceptable.

We are a military organisation and risk is inherent in the frontline job. That said the bottom line is can the risk be reduce to as low as reasonably practical whilst looking at the operational necessity of completing the job.

[Exrigger]

Where we currently are the RAF OSI team and our MEDA investigators work together to get to the root cause of the issues when required to.

A simple tool that needs no training in is called the FAIR model (used to be called the culpability slide/slope/chart), the only problem is there has been the odd time when great discussion has taken place to try and get a person over the 'line in the sand' with a view to some form of disciplinary action, which is obviously not part of Human factors and the 'Just Culture' theme.

[whowhenwhy]

Around 2 years ago Spry I mentioned in a mtg with IFS that whilst the concept of Just Culture was developing across Defence (and developing well in some areas/specialisations) in others, like ATC, it was inconsistent. The whole thing is hugely personality dependent and, being in a position to see the data on a daily basis as I am, you can see the change in reporting levels within 2 weeks of a new SATCO arriving in post. Unfortunately, both positive and negative. The only thing with the meeting a couple of years ago though was that I distinctly recall one Group Captain asking me why Just Culture within ATC was lagging when we have 'Regulation and Policy that states that we shall have a Just Culture'. It was then that I related the old story of the reluctant pony at the watering hole. Sadly, he just didn't understand.

There are many reasons behind the problems but resolving 2 would go a long way to solving the whole problem. Firstly, education. As an organisation we need to fully understand the human source of error and its inevitability but also how we can manage that human activity on a day-to-day basis to get the most out of our guys and manage error. Our HF trg is well intentioned but, given its generic nature, it makes it harder for our people to apply the principles directly to their own roles. It then, slowly, becomes perceived as a box ticking exercise because the guys can't see the operational benefit. The second issue is resourcing, as has been mentioned earlier in the thread. To do this 'safety work' effectively we need additional resource, which means a bigger tail for the dog OR, it means getting the politicians to think long-term. Spend big on infra-structure etc for a couple of years but then you'll have a smaller outlay in the following years. There's a lot of real estate and sacred cows out there that we don't need.

[Uncle Ginsters]

Sir,

Just Culture is inextricably linked to Open and Honest reporting, and vice-versa.

The problem that you have is that both are hard won and very, very easily lost and if you lose one, you lose the other.

- So long as ASIMS authors are being hauled over the coals by VSOs in front of their peers, you have nothing.

- So long as line managers choose to punish genuine HF errors so obviously linked to wider issues, you have nothing.

The list goes on...but not for this forum :}

The guys n gals on the shop floor are all for it, just sort the upper echelons out first.

[VinRouge]

As stated previously, the only way to truly engender change is to eliminate those who blatantly disregard it.

Until the dinosaurs are extinct, you will still remain liable to be eaten.

[Mach Two]

For this to work we need to trust those "in the chain of command". Very much like the "anonymity" of our posts here, any reporting or posting system only remains anonymous up to the point when someone feels the need to delve deeper and over-ride the pledge of protection. That is a clearly stated policy - and for sound reasons. Be careful what you own up to.

[AutoBit]

I've edited my last post as this is a public forum, but in short the 'Just Culture' comes somewhere down the list of priorities these days if other factors can be seen to bring the Services into a bad light.

In those circumstances Im not sure being fair and /or 'Just' is the number 1 priority.

[Dan Winterland]

The big problem for military Flight Safety is the "alpha male'' commander/manager type that exists within the command structure. Their tenure is short and they don't want anything happening to bugger up their chances of promotion on their watch. This pervades the whole system - all they way to the top They want to know everything and are only too happy to apportion blame where they see fit - and which is rarely on their own doorstep.

I was a FSO in the RAF and am now a FSO in an airline. Airlines too tend to have just culture issues which stem from the managers not wanting to leave the system alone and let it run naturally. They cite responsibility and legal liability as reasons for their attempts to micro manage safety which often have the effect of stemming the flow of information and effectively destroy the concept of a just culture.



The need for a just culture.

But the problem with any data system related to safety is that management can view it as a useful tool for monitoring. Using collected data to police your employees is empowering and attractive to the manager who has limited trust in his safety system. They sometimes feel that their corporate and legal responsibility is to know about and deal with any; or even all transgressions. However, data collections systems can only pick up certain recordable and tangible errors. There are many more which cannot be recorded and for a safety management system to be informed of these errors through voluntary reporting; there has to be trust. Another way of describing this is that a ‘just culture’ must exist and be seen to exist. A manager must accept that there are certain events which they may get to hear about and that they can do little in response. This can make managers feel vulnerable; but they receive greater remuneration and benefits to shoulder such risks. The increased flow of information from voluntary reporting completes the ‘safety picture’ and it is an industry accepted view that this enlightened safety culture is in fact the best policy.

However, this runs the risk of some individuals treating this as a ‘get out of jail free’ card. This is not and can never be the case and the workforce must be made to realise that any such action in the category of recklessness will be dealt with. How this is dealt with is again a case for conjecture and depends on the circumstances and the transgressor. A defined system of discipline and in the extreme cases, punishment must be in place. But using punishment must be done in only the most severe instances, as often the transgressor will attract a level of sympathy from their peers and the safety system will suffer. A very effective form of discipline can be maintained if the peers themselves highlight the fault and let the transgressor know that they have overstepped the mark. Their professionalism will always refuse to accept one of their members taking risks and in such cases, non-acceptance of an action by one’s peers is often far more powerful a deterrent than admonishment or a penalty administered by a manager.

[Exrigger]

Dan Winterland: They cite responsibility and legal liability as reasons for their attempts to micro manage safety which often have the effect of stemming the flow of information and effectively destroy the concept of a just culture.

A manager must accept that there are certain events which they may get to hear about and that they can do little in response

The increased flow of information from voluntary reporting completes the ‘safety picture’ and it is an industry accepted view that this enlightened safety culture is in fact the best policy.

I have extracted the above three as these are the issues caused by in the main lack of understanding by management of what they think is being promoted by a Just Culture and protecting their careers, and this is within the military and civilian industry supporting it.

You are also correct that some think it is a 'no blame' culture and again it has been by the use of the previously mentioned FAIR tool, that if the occurrence steps over the culpability line then some form of discipline will be forthcoming, again this is a education, communication and understanding process as the whole Human factors process is, get it wrong and base it on incorrect assumptions and 'interpretation' and it is going to fail.

[Rigga]

I have been involved in an RAF technical investigation where - as a civilian witness - I felt as though it was me going through a court marshal!

It will inevitably vary from station to station and/or fleet to fleet and it will be best served by individuals not by the systems used, but as long as you have investigations and routines conducted in a rough-shod black-and-white manner your culture will remain negative despite any reporting culture you pretend to have. (works like this on the outside too, BTW)

[MechGov]

Just culture? Not always. If it were, no one would have to submit a DASOR to the Sqn executive before pressing send.

[Gnd]

Good thread and worth the effort to reply. The main problem with the Just Culture is the chaps don’t believe the ‘leaders’ in their world do it; it is not a blame free culture but the higher you go the more toward blame it goes.

Problem across the MoD

Navy – Pretty good but do not like others having ideas they should have had.
Army – It has always been this way and who are you to tell me I am wrong?
RAF – We are the Air Superiority expert so how can we be wrong?
DE&S – Why would I possible interested in what the Armed Services think?

Answer, take the process out of the single service domain and put all Assurance, Audit, Trending and SI/OSI into the Joint Force Command so there cannot be any parochial behavior and we would also be independent a la Haddon Cave; we are not at the moment. (And not fill the top up with one service!!!!! – Mr G?)

I totally agree that there is fatigue with visits and this must be a number one priority if we are going to take the body of the Kirk with us – I feel for the worker bees, they are over persecuted!!! Pilots, thechs get over your rivalry and work together!

[A and C]

The civil aviation world has talked often about a just culture and open reporting of incidents, the way companies deal with this varies greatly.

The best practice in this field I have seen is in the Scandinavian airline that I currently fly for, they encourage Incident reporting as the best way of getting flight safety issues out in the open, this along with the statistical data from the FDM (with the crews identity removed) and you have a very powerful flight safety tool that enables the company's training department to address the common shortcomings and errors made by the crews in the simulator training. By UK standards the whole thing feels a bit touchy- feely but it works well, no one is reluctant to report any problems that they have had and the management is pleased to get the truth from the coal face as if they use the data properly it can stop problems almost as soon as they start. Most important is the managements positive attitude to reporting of the honest mistakes that pilots have made.

Another LOCO airline in the UK takes quite a different view of FDM with any event resulting in instant removal of the crew from the flying program and retraining before that crew member can resume flying, I am told that this is at the insistence of the company lawyers who take the view that if they don't carry out "retraining" and there is another Incident or accident involving the crew member the company might find Its self in legal hot water. I can only shudder to think how little real world feedback the company generates and how little the training department can taylor the recurrent training to the real world situations that the crew are likely to face.

The RAF has a very difficult square to circle in that military discipline has to be maintained and this usually results in very clearly defined individual responsabilitys that if not met can result in disciplinary action and on the other hand the knowledge that people make unintentional errors has to be recognized. The flight safety system needs data about these errors to identify root cause and if they are common put in place a system of training to correct the issues.

A blame culture will only encourage those who make a mistake to cover it up if they can, if one person makes a mistake you can be sure that others have made the same mistake. In the Scandinavian airline these mistakes would be reported and published in the monthly flight safety review, this data would also be reviewed for inclusion in the six monthly simulator practice. In the RAF if an open culture is not encouraged the first thing that is known about these problems is when an accident has happened and a number of people in the crew room comment quietly to friends that they were almost a victim of the same problem!

As the blame culture is largely due to the management shifting blame as a necessity for career progression any change is going to require a big change in the attitude at the very top, the only question is do the RAF have a person in the upper management who is capable to take a very statesman like approach to the ingrained blame culture and remove it.
I know that the military have a hard time differentiating between a mistake and negligence and tend to treat the victim of the former like the perpetrator of the latter but if the culture can be changed it will have far reaching positive effects on flight safety without any negative effect on military discipline.

[Rigga]

Can't say much better than A&C.

:cool::ok::ok::):):D:D

[thefodfather]

When ASIMS and the D-FSOR were first conceived, the situation discussed by A&C was the ultimate goal in the long term (and I mean "long" term). As we've seen from the many replies on this thread there still appears to be some way to go, but it's a big and diverse organisation so it was always going to take a while. Without doubt the key thing is leadership. Years of hard work can be undone with a single ill thought out response to a safety incident.

None of this really should be a surprise to anyone though, at least not these days. But after the turmoil of the past few years in military aviation and since the establishment of the MAA are there enough senior officers out there setting the right example?

[Arthur1Daley]

Delighted to see Wg Cdr Spry starting such an interesting if not potentially toxic thread.

The contributions cover a broad range, some are well informed and recognise Spry's efforts to gain a wider appreciation of how RAF personnel, aviators and engineers in particular feel about Just Culture. Other contributions are less helpful but may reflect an individuals experience in the past, when subject to the desire of a zealous commander keen to make an impression.

That said, a Just Culture is NOT a blame free culture. If someone has been properly trained and makes a mistake without good reason or cause, that is blameworthy. They should not expect a pat on the back and some kind words before being told to 'carry on'. Aviation is complex and potentially dangerous, it involves peoples lives - all RAF personnel are well trained and paid good money to avoid simple or inexcusable mistakes. That said, the FAIR tool still allows for errors caused by systemic pressure or organisational failings - so I think it reasonable to say that the RAF attitude to a Just culture is, at the middle management level, considered and effective.

My concern is that our senior officer cadre continue to look up and careless for those doing their best. No doubt the Inspector is doing his bit to change that approach but ask the various AOC's who are vying for 3 star rank and they have very little real interest in the personnel under their command. Until we can break that self centred and mainly self serving command cycle, things will never change and trust will be a distant hope.

I hope that we see some feedback or comment from the good Wg Cdr very soon.

[Easy Street]

The trickiest area of the FAIR system is the treatment of non-culpable errors. I know that some are under the impression that genuine, honest mistakes should not result in action being taken against their maker. However, as we know, student pilots who repeatedly make mistakes (however honestly) are liable to be suspended for lack of ability. Reaching the front line does not render one 'safe' and the suspension process continues to be avaialable throughout an individual's career. Night AAR is one example that occasionally catches out those who think they have 'made it' when they join their first squadron! This is only right and proper, but it does make application of FAIR a bit of a pickle. How many genuine mistakes can someone make before they become a cause for concern? Should you apply a remedial training package to every mistake, or wait for a second, related mistake?

It all comes down to judgement, and it is easy to see how mis-perceptions can arise. 'Pilot A', a capable pilot with a good track record, might land below diversion fuel, debrief the incident appropriately to the Duty Auth, submit a DASOR and hear nothing more of it. 'Pilot B', with a chequered flying training record and a propensity for minor errors, might land below diversion fuel, submit a DASOR and find himself in front of Flt Cdr Trg signing review paperwork ahead of a remedial training package. To those without knowledge of the individuals involved, it's easy to see everything through the FAIR lens and view this as unjust, whereas it's actually the flying supervision system going about its normal business.

It's important to note that suspension from flying duties for lack of ability is not a disciplinary matter!

[thefodfather]

It has been interesting to see the various comments on this thread and particularly the different interpretations of Just Culture. I am sure that a lot of the differences are simply about the use of terminology, I would like to pick up Arthur Daley on the comment about the concept that Just Culture is not a blame free culture. The simple fact that military aviation personnel are well paid and well trained doesn't step away from the fact that the foundation of Human Factors and Just Culture is the concept that to err is human. The suggestion that making a mistake is blameworthy in any way shows that there is still some way to go in the understanding of Just Culture in the middle management as well as the senior management.

Humans will make mistakes by their very nature and a good organisation should encourage people to report their "simple" mistakes so that others can learn from them. My take on it, for what it's worth, is that what we actually mean is that people who break the rules without good reason or cause should be blameworthy. There is quite a significant difference between the 2 and that is the difference between a good safety culture and a bad one, where people are scared to report their mistakes for fear of the consequences.

However, what the FAIR system and Just Culture is not there to do, is to replace the normal activities of a functioning supervisory system. It is easy to confuse the 2 things and I think that Easy Street has hit the nail on the head. FAIR should not lead people to expect that their performance won't be appropriately managed just because the Just Culture says they aren't blameworthy.

[Exrigger]

thefodfather

However, what the FAIR system and Just Culture is not there to do, is to replace the normal activities of a functioning supervisory system. It is easy to confuse the 2 things and I think that Easy Street has hit the nail on the head. FAIR should not lead people to expect that their performance won't be appropriately managed just because the Just Culture says they aren't blameworthy.

Quite correct, when I posted reference to the FAIR tool I only gave an example of what was considered an attempt at mis-use (bit one sided I realise now), we on the whole do look at the people involved and still thankfully get people to hold there hands up to mistakes and personnel are told that allthough disciplinary action is not required there has been education, training and communication to individuals and the whole work force as appropriate, via supervisors and management.

We have several times in the past caused engineers to stop reporting errors/mistakes as different managers reverted back to blame/discipline culture, again thankfully that was a quite a few years back.

[dervish]

Many of the posts discuss mistakes. MoD is in the poo because of deliberate acts and concealing those acts; not mistakes. The likes of FAIR helps address the former, but the latter can only be addressed by instant dismissal. IMHO.

I have some old MoD literature from 2002 on the subject which is poor on presentation, but eventually gets there. Under the title of “A “Blame-free” Environment”, it says;

“Safety Culture requires an atmosphere in which individuals are not unduly punished or blamed for their mistakes – a “blame-free” environment. This is an ideal which is difficult to achieve in practice: when things really do go wrong, people’s reaction is often to protect themselves by pointing the finger of blame at others.

Even an organisation that strives to achieve a blame-free environment is still subject to rules and legal regulations. A “Just” culture is one in which individuals are not free of blame if they are culpably negligent, and where the organisation gives due regard to honesty. Errors and mistakes are inevitable, and safety can only be improved if the organisation can learn from its mistakes”.

I think a “However” if required before “A Just Culture” to separate the two concepts.

In MoD certain levels ARE free of blame when culpably negligent, honesty is NOT given due regard and lessons aren’t learned. And somebody from MoD has to post here, now, asking for opinions? :ugh:

[Gnd]

Arthur1Daley (http://www.pprune.org/members/240199-arthur1daley)
I am afraid, although valid, your parochial and possible blinkered comments direction is why we will not get to the Just Culture soon - Note my comment on the RAF's view on others. We are not the only show in town and if you look at ‘accidents v’s Hrs v’s airframes - the RAF are no shining beacon. Let’s get this done with the 4 worlds and 4 Services (even the Civvies if we have to!). We already get bad rep for being snobs, lets not fuel that rep – and – why have the RAF got 4 layers in the 1,2,3rd party assurance piece.

1st Party – Base/Station
2nd Party – ODH
3rd Party – MAA

Where do RAF FS (or should it be AS) and GP fit into this system that is meant to be simplified according to the accepted HC report? Are we again just saying we will and ignoring everyone else? Not sure the Army or Navy have kept this complicated over layered approach that must make it harder to administer a just culture?

PS – ‘Military Aircrew’ isn’t a single service term? Should we start an RAF only Forum?:ok:

[Wetstart Dryrun]

Just too many politically driven Air Martians.

...no, just too many

wets

[Chugalug2]

If the RAF operates a truly Just Culture regime, how come it still blames the Mull pilots for that tragedy, despite the palpably unjust Wratten-Day Finding being set aside, and those Air Officers that ordered the Chinook HC2 into service via an illegal RTS go on being protected? I suspect that the Wing Co will once again remind us that such matters are way above his pay grade and that he is simply trying to do his job. In fairness to him he can't, while the MAA is hamstrung by the Star Chamber.
All that is left now for RAF Flight Safety (or whatever it is rebadged to), is to go through the motions of publishing magazines online, putting up posters, and keeping people occupied with threads such as this.
If RAF Flight Safety were all about presentation then it would no doubt receive "Publisher of the Year" awards aplenty. It is of course about avoiding air accidents, and learning what it can about those that are not avoided in order to avoid them in future. The present arrangement of self-regulation and self-investigation is a sure way to ensure that does not happen, witness the Airworthiness Related Fatal Air accident threads on this forum that account for 62 deaths alone.
Someone, somewhere, has to stop just doing their job and start the MAA and the MAAIB on their way to complete independence from the MOD and of each other. Then they'll have to learn to do their jobs properly, which will be a very steep climb indeed!

[VinRouge]

Well, soon enough, if we have another "Biggie", the RAF and MOD will learn as a whole that self-regulation isnt a god given right, as some seem to think it is, its a privilege that as I understand it, was nearly pulled post HC

Just culture? Not always. If it were, no one would have to submit a DASOR to the Sqn executive before pressing send.

Name and Shame!

[Dave Wilson]

Troop the buggers once in a while, if the procedure is in the book and they willfully ignore it, they are breaking the rules and need to be told so.


It's a long time since I was in but if we had followed procedures by the book I doubt whether any aircraft at all would have been generated which would have generated a ****storm from above. Of course sometimes things went wrong through not following the book which generated a ****storm from above. Heads they win, tails you loose.

Keep the flying program going and we'll look the other way until the board of enquiry at which point your on your own.

[OKOC]

Ladies and Gentlemen RAF Aviators,

Nobody in your promotional /Management Line-manager/sqn chain actually gives a flying **** about you, despite their smiley assurances. Yes, you may receive a Christmas card from your boss whatever level you are at this Christmas but when they/you leave the sqn do you ever hear from them again? No of course you don't. Shallow ****s.

Just don't **** up ever--or they will screw you. It is truly dog-eat-dog-except you don't have a dog to eat.

[Just This Once...]

Well, soon enough, if we have another "Biggie", the RAF and MOD will learn as a whole that self-regulation isnt a god given right, as some seem to think it is, its a privilege that as I understand it, was nearly pulled post HC

Quote:
Just culture? Not always. If it were, no one would have to submit a DASOR to the Sqn executive before pressing send.

Name and Shame!

I would guess at 8 Sqn given that the resulting backlash is neatly recorded on ASIMS for everyone to read.

Do I win a prize?

[Lima Juliet]

OK

I'm Facebook mates with 3 of my old sqn bosses. I send Christmas cards to these and I share a beer with all of my ex sqn bosses every year...

Myth busted!

LJ :ok:

[OKOC]

Leon,

Well done. :D

[Party Animal]

I'm Facebook mates with 3 of my old sqn bosses. I send Christmas cards to these and I share a beer with all of my ex sqn bosses every year...



Which explains why Leon went from Plt Off to Wg Cdr in 9 years! ;)

[1.3VStall]

I am still in touch with three of my former sqn cdrs and regularly see them at formal and informal reunions. Mind you, we all emanate from the era when we had leaders and commanders, rather than managers and executives!

[dallas]

The trouble with the system of DASOR is that every career chiseling bluntie gets to put his two penneth in because he once flew on ops. The amount of senior officers who 'climb into your cockpit' and pretend that they wouldn't have made the same decision as you is staggering.

They only do it so that they can get noticed putting the boot in. Nothing to do with learning lessons on AS. Stop it you burks....

The big problem for military Flight Safety is the "alpha male'' commander/manager type that exists within the command structure. Their tenure is short and they don't want anything happening to bugger up their chances of promotion on their watch. This pervades the whole system - all they way to the top They want to know everything and are only too happy to apportion blame where they see fit - and which is rarely on their own doorstep.

The two posts above hit the nail on the head for me. The military is an unforgiving organisation, where mistakes - from a button undone to gear being left up - are punished - it is fear driven, but broadly improves discipline and effectiveness, and 'tree-hugging' (openness and forgiveness) have never been part of the culture. Add to that the parallel culture that has prevailed in the last 20 years as the RAF has shrunk: promotion/pension at any cost, and the conditions are toxic for any sincere attempt at a Just Culture.

Interestingly, I hear EasyJet have a model safety culture that has borne dramatic reductions in accidents/incidents as the culture prevailed. As a result they have saved a fortune in operating costs, let alone potential lives. But as my source made clear, and as several have said here, you can't just declare a culture in SROs - it has to be nurtured, which means those who turn to it in the spirit intended are genuinely supported by senior officers who have the integrity to see the end game as more important that their pensions. Or is that the underlying snag?

[Rigga]

Dallas,

You are correct in saying that it isn't just "the system" that works - its the people driving it (those at the top?) who matter just as much as the system. Replace one or two of those key drivers and the system is almost always going to slip until someone else gets a grip with how to handle it. Put the wrong people in and it will collapse.

I know one of those EasyJet SMS people and he is a great driver.

"A man can do one thousand good things but he will be remembered for the one thing he does wrong."

[Easy Street]

Just culture? Not always. If it were, no one would have to submit a DASOR to the Sqn executive before pressing send.


I've seen this practice on a few units and in my experience the reason has not been to suppress reporting. The risk of being CONDORed by a switched-on safety-aware subordinate, with the inevitable sh*t-storm following close behind, is surely enough to deter even the most ambitious pole-climber from trying to manage down his unit's occurrence rate! Rather, as I've seen it, exec involvement in DASOR submission has been intended to ensure that sloppy or extraneous wording is avoided.

Now, loose or sloppy wording in a DASOR should not be a problem... the point of the system is to get occurrences recorded, and if the language is somewhat less than perfect, so what. Unfortunately the early days of ASIMS showed that if indignant ivory tower-dwellers could detect even a sniff of human failing then critical comments and requests for further clarification would inevitably follow. I think some units came to the view that it was worth the effort to put out a water-tight DASOR at the first time of asking, rather than go round in circles wasting supervisory capacity trying to un-f*** the mess that can arise from a quickfire submission.

[dallas]

At a bizjet company I worked for it was seen as an indicator of good departmental management to have a healthy number of incident/occurence reports, as this was viewed as providing an opportunity to spot patterns and manage safety, thus saving money/rep/lives as the long term win. Staff were almost chased to submit stuff, and the FS team genuinely looked at each report as a learning opp. Perhaps this should be introduced as a KPI for mil commanders too - it would certainly force through the culture and be an antidote to chisselers at different levels, if they viewed no. of reports as a scorecard.

[A and C]

Easyjet is undoubtedly a well run airline from an air safety point of veiw with the number of incidents driven to a very low level.

However I get the feeling that they have driven down the number of incidents by a ridged procedural flying policy and discouraging manual flying, my evidence for this is that they usually are very reluctant to take a visual approach even when the conditions are very good VMC. Approaches to Nice are a good example I always seem to be behind an EZY who is insisting on doing the full VOR approach when all I want to do is fly around the cap Antibes and land. May be I'm just unlucky and have a new first officer on line training in the EZY in front of me.

The situation the military have is that the operation is incompatable with a very ridged procedural system and has to encourage the basic hand flying skills rather than use of autopilots, by the very nature of the operation, military flying will have more inccidents and so puts an even greater strain on those trying to instill a blame free culture.

[Exrigger]

Sorry dallas, but to make the input of reporting a KPI is the exact opposite of what you should do, there is talk of doing that around where I work, the problem with getting as many as you can into the system so it looks like you have a just culture is the system gets swamped and as no one can afford to sustain a healthy clearance rate, due to financial and commercial constraints mostly.

Closing the issues out in the correct manner to satisfy the person who put the issue in is the most imperative part of the process, if you don't close them and put the right process/equipment/people in place people get disillusioned and give up on the system and then you run the risk of missing the one that will stop the accident happen, which is even worse than not meeting the KPI.

Again a KPI was being muted for closure rates, but this is also unattainable and impracticable for all the reasons already stated.

You can also end up with open legacy issues and trust me you can get personnel to put all sorts into the system if you push them hard and long enough, and a lot of those should not and do not need to be put in as there are other methods of raising those through audits, suggestions boxes, GEMs etc, having a form of KPI to be met was attempted with Health and Safety kaizons and that was not very successful and is not utilized.

Back to the financial/commercial and dependency issues when it becomes to difficult it is either closed with some lame excuse or put onto the Risk Register or Hazard Log and that is also considered the issue sorted.

[dallas]

Yes, that's true re: EZY, and safety is a lot easier to manage with a scheduled service or pattern, but there are still a lot of commonalities remaining between types, units, commands and arms. And even then, best practice can be developed to apply to greyer situations, based ideally on previous experiences and incident/accident reports.

I think it's interesting that 15ish years ago the RAF would have been hailed as a paragon of flight safety, with Air Clues etc often being sought by civvies for training, and yet somehow it now finds in itself on the back foot in terms of culture to EZY et al - notwithstanding your observation above. I wonder if the next big enquiry will ever connect the shrinking size of the services to narrower oversight mechanisms that became contaminated with ambitious individuals; the latter certainly buggered up a lot of other stuff!

[Rigga]

The point of getting lots of reports into the system (and to make the reporting levels a KPI) is to get staff generating reports and used to the idea of submitting them. The fact that you're still doing this signifies that you're still in the "Reporting Culture" or earlier stages and a fair few cultures away from being "Just".

Does that spinning Campbell chap do the PR for the SMS system now?



I think EZY goes for the earliest stabilised approaches to get their fuel costs down too.

[Lima Juliet]

Which explains why Leon went from Plt Off to Wg Cdr in 9 years!

18 actually, but it doesn't explain why I go to work with a lower rank badge on my shoulders these days... I think T E Lawrence started the trend! :ok:

LJ

[Just This Once...]

Ah but your take-home pay is somewhat ahead of the rank on your shoulders me thinks.

:ok:

[CoffmanStarter]

Leave Leon alone ... he's had to wear a new type of Bonedome recently ... and no he's not gone SAR

http://i1004.photobucket.com/albums/af162/CoffmanStarter/image_zps56d132f8.jpg

[A and C]

The early stabilized approaches are less fuel efficient but the policy had advantages with insurance costs.

The constant descent approaches are the fuel saver with that ultimate aim being to glide from cruise altitude to touchdown, but in practice the power comes up to fight the drag as the aircraft is stabilized in landing configuration before 1000 ft AAL in line with company SOP.

[Lima Juliet]

Coff

There's nothing cushey about the Womens' Auxilliary Naked Korps of Firefighters, I'll have you know (you can shorten the name, if you prefer, to its initials :E).

LJ :ok:

[Rigga]

Cheers A&C - As you can tell, I'm better talking about hellycopeter Nuts & Bolts.

[orgASMic]

What a cracking bit of fishing from Wg Cdr Spry, eh? Throws out the bait and sits back as the huddled masses throw it back out of the water

Sir, as the instructors on CATCS used to ask at the end of a sim slot "How do you think that went?" Not as well as you planned, or better?

As for me, I think my part of the organisation is in a pretty healthy learning phase; plenty of open, honest reporting uncovering some personal, managerial and procedural short-comings which can mostly be attended to locally and with minimal fuss. Is it Just? It is trying to be; awards and sanctions have both been dished out. Is it perfect? Far from it but it is effective. The important thing is that the Boss is making it happen by taking an interest and lending his weight where necessary; he is confident enough in us to let us sort most of it out and then report back. Long may that continue. If it does, then we will be on our way to lasting cultural change.

[Chugalug2]

orgASMic, you are absolutely right about the importance of a good Boss, the most important person (or bloody well ought to be) in any military organisation.

Therein lies the W/C's dilemma, for the RAF Flight Safety organisation that he represents is founded on the assumption that all is well above, while it is those below who need to be educated and encouraged in matters of Safety. The recent history of the Royal Air Force though suggests that the opposite is the case, and sadly there is no mechanism for him to address that, as he has tacitly admitted on his sticky thread. Even if there were, the Star Chamber has more important considerations on its mind, ie covering up the sins of their forefathers lest they in turn be exposed.

That is why RAF Flight Safety needs to be completely reformed, by making Regulation and Investigation (the two means of ensuring it from above) independent of the MOD and of each other. The MAA and MAAIB should be sistered with the CAA and AAIB respectively to become the military sides of those two bodies and be led by civilian DGs with seconded Service personnel. That way his dilemma can be resolved and he can then get on with his job of educating and encouraging with the assurance that it can then work effectively.

[whowhenwhy]

Agreed. The MAA concept is sound but severely flawed in that it is manned by people from the front line who are on 2/3 year tours.

[dervish]

manned by people from the front line

And so by definition know the square root of eff all about the problems that caused all this in the first place. Having read the evidence I now realise I knew next to nothing about what makes an aircraft airworthy. I only knew how to make it serviceable.

[Rigga]

Thank you Orgasmic for supporting the need for a good boss.

Just think what a difference that one person makes compared to those that you dont want to work with.

A particular position and/or personality affects any culture - good or bad.

[thefodfather]

Chug raises an interesting dilemma about RAF Flight Safety. If the MAA is the regulator, independent or otherwise, are they not really the equivalent of the airline safety department?

[whowhenwhy]

Now we're getting somewhere. IMO, the next logical step to that argument is to look at the Gp and/or ODH structure. Why do we have so few platforms split across so many masters? Why do all of the ODH insist on assessing and managing Risk in different ways, given that the required output is the same in terms of the Regulatory intent?

To answer the previous poster, the RAF Safety Centre is exactly akin to an airline safety organisation which would report direct to the CEO. Each functional area then has it's own safety specialists. Of course in our case it would help if we had some BM guys doing BM assurance work, rather than an aircrew mate and some engineers. Not knocking the individuals BTW, who are doing some good work.

[Chugalug2]

tff:-
If the MAA is the regulator, independent or otherwise, are they not really the equivalent of the airline safety department?
Definitely otherwise, and like any airline safety department is obliged to do as its employer dictates at the end of the day. "Independence" seems to depend upon no such dictates being made. Given the evidence that dervish refers to, we can have no confidence in such assurances being adhered to in the future.
Independence not only has to work, but be seen to work. A truly independent MAA and MAAIB, separate from the MOD and from each other, sistered with the CAA and AAIB respectively, and headed by civilian DGs will thus work. Then, and only then, can the long long task of rebuilding and restoring UK Military Flight Safety begin.

[orgASMic]

Chug

While I agree in principal, why does the DG need to be a civvy? The RNLAF's equivalent organisation (the closest any other nation has to the MAA) has a serving 1 Star DG but the difference is that the incumbent must be on his last tour of duty so that he is not worried about his promotion prospects. Could that work for us or would people worry that the DG would then not care enough to do a decent job as it would not matter to him?

[airborne_artist]

The RNLAF's equivalent organisation (the closest any other nation has to the MAA) has a serving 1 Star DG but the difference is that the incumbent must be on his last tour of duty so that he is not worried about his promotion prospects.

But what about his chances of getting a good job thereafter in civvy strasse? Comply and be recommended as a good egg by other serving/recent VSOs or fight his corner and be tarred with the "bolshie" brush?

[dervish]

This was discussed a few years ago and one conclusion was a last posting civvy would be ideal as their retirement age is 65 and fewer seek second careers. The stumbling block today is fewer are trained properly, which could also be said of servicemen of course. I'd wager none could write the evidence submitted to Phillip, which I'd also wager the MAA finds embarrassing.:E

[orgASMic]

But what about his chances of getting a good job thereafter in civvy strasse? Comply and be recommended as a good egg by other serving/recent VSOs or fight his corner and be tarred with the "bolshie" brush?

Or, perhaps, fight his corner and be tarred with the "professional" brush? And then be recognised for having made a genuine improvement to the system? Perish the thought.

The only thing lacking in the current system is moral courage.

[dallas]

The only thing lacking in the current system is moral courage.
IMO that's been broadly lacking from the junior officer corps since the mid-90s, where achievement has been measured in departmental name changes, fringe and faddy projects and chronic short-termism.

[orgASMic]

Do you mean 'the officer corps of the Junior Service' as opposed to the junior officers of that service, as they don't get to influence the sort of nugatory staff work you cite? In my experience, you are more likely to get the truth from lower down the food chain. Maybe that's why I am never going to be a wg cdr.

[EAP86]

"The RNLAF's equivalent organisation (the closest any other nation has to the MAA) has a serving 1 Star DG..."

Quite a few European nations besides NL have a similar approach to the MAA, e.g. France, Sweden and Finland; and on other continents, Australia and Canada also come to mind. I don't know of any that are as independent as some would seem to prefer. Haddon-Cave made a mini-world tour looking at a few of these MAAs before writing his report.

As an aside, the last incumbent for Director of the NL MAA was Air Commodore Chris Lorraine, a Brit.

[Running_In]

Orgasmic, I agree that a lack of moral courage within the RAF is the problem, although I would blame the Wg Cdr and above level. They are the ones that set the tone for the Sqn and the operators are usually at their mercy.

I was witness to someone committing a few acts of willful gross negligence in the air when I was on a Sqn based at Brize. I told my Flt Cdr and together we told the Boss as a courtesy before reporting it to the RAF Police (as some of the incidents went a bit further than flying discipline) and Stn Flt Safety. The Boss' reaction was a bit out there frankly - he was unashamed in being explicit that his priority was protecting the reputation of the Sqn. I was ordered not to take it any further, but I decided to report it to the Police anyway. It came to head with the Boss phoning me at 8.30pm to tell me he would make sure my next job was in M&S if I didn't with draw my report! He also pulled a reason out of his backside to ground me from flying myself that same evening.

The reaction I'd witnessed scared me and as you said, it demonstrated that on that Sqn at that particular time there was a complete lack of moral fibre and willingness to put the effort into self analysis.

[Chugalug2]

orgASMic:-
why does the DG need to be a civvy?
I'm afraid that the betrayal in the late 80s/early 90s by certain VSOs of their duty, by issuing illegal orders to suborn the Airworthiness Regulations and by sacking those who would not comply, make that quite impossible because those who did comply (thus acting contrary to Military Law) have never been punished for it. In contrast those who did not comply have suffered greatly, much as Running In describes. You either learn the lessons of history or you are doomed to repeat them.
I would guess that the RNLAF has not so been betrayed by its High Command. That is its good fortune. The RAF that I served in was not thus betrayed, as far as I know. That is my good fortune. All that changed post 1987, and that is the reason that we must ensure that it must never happen again. If the MAA DG is civilian, it shouldn't, providing the MAA is outwith the MOD.
I cannot comment about the moral fibre of the present RAF leadership, for that is the business of the RAF, though it is sad to think that it could be wanting. Flight Safety though is my business, I was told that when I served and I still believe it to be true

[dallas]

A predominantly civilianised MAA was something I was going to mention. It's one type of organisation that would benefit greatly from a static staff, independence from the chain of command and, God forbid for a safety/regulatory authority, have the ability to learn.

[dervish]

A predominantly civilianised MAA was something I was going to mention. It's one type of organisation that would benefit greatly from a static staff, independence from the chain of command and, God forbid for a safety/regulatory authority, have the ability to learn.


That point is made here.......

https://sites.google.com/site/militaryairworthiness/8-the-military-aviation-authority-maa


To paraphrase, the failures were spotted and reported by civvies who were hounded by RAF VSOs. (Which I think is accepted now.) Yet none of these civvies are in the MAA and nor has the MAA sought their input. (Can't comment but it is accepted the MAA isn't addressing the failures that resulted in its formation.) The MAA is dominated by RAF officers, whose past and present hierarchy was responsible for the failures and still sees no wrong in what it did. (I think also widely accepted given their outpourings in the press.) IMO, the main point the author makes is that on MoDs own admission no member of the MAA reported failings, which either means they are unsuited or lacking moral fibre. Pretty strong argument IMHO.

[1.3VStall]

There are few people, not many, who have been senior engineering officers in the RAF/MoD and have subsequently gone on to hold executive positions in the airline industry as CAA Nominated Post Holders and even CAA Accountable Managers. These people thus have direct experience of airworthiness regulation and implementation in both the military and civilian arenas.

One might think that such knowledge and experience would be of direct relevance to the MAA, yet I am not aware of any of these people being contacted by the MAA.

Whilst I am sure that Baines Simmons, a respected consultancy, has provided the MAA with good advice (at what cost?) I can't help feeling that the MAA has missed an opportunity to tap into expertise that would have helped the organisation in its early years.

[A and C]

1.3V stall, I have found that there is a small but very vocal minority in the RAF who think that there are two ways to fly......... The RAF way and the wrong way.

I suspect that a little of this culture has crept in to the decisions that resulted in the set up of the MAA.

[Splash1983]

There seems to be a misconception that the MAA is solely about Air Safety - It is not, it is the Regulator in the same way the CAA is the national regulatory representative of EASA. In that way it assures airworthiness and audits; application of regulation, management of Risk To Life (RtL) and the individual Duty Holders.
Making it a civilian or civilian led organisation would potentially fall back into the previous traps of malaise that befell certain IPTs in the past.
Military Flight Safety is not the issue, inter-service bickering at the senior levels and individual failings have been.
I do like the suggestion though, that the DG should be at the twilight of his career and therefore not be seeking further promotion.

[1.3VStall]

Splash,

it assures airworthiness

Do enlighten us on how the MAA does this. Unlike the CAA, which is wholly independent from the operators and government, the MAA is not independent of the RAF, nor the MoD.

[Splash1983]

By the use of SQEP (Suitably Qualified and Experienced Personnel) staff, who have the appropriate skill and qualfications to review, monitor and audit. It isn't rocket science, but needs both sides to be professional, diligent, aware and not cut corners. At times therefore it may be initially painful, but ultimately beneficial.

I'd question how independant the CAA is of Government as it is funded by them and sits below DfT. Probably not too much more or less than the MAA in many ways and effectiveness. The real difference is between the MAAIB and AAIB and the MAA and CAA!!

[Engines]

Splash,

I might be able to help here a little. I'd argue that the MAA really is all about Air Safety. Its website gives these definitions:

MISSION

Enhance the delivery of operational capability through continual improvement in military Air Safety, appropriate culture, regulation and practice.

VISION

A world class military Air Safety regulatory and assurance model that is proactive, innovative, modern, efficient and effective.

Now that looks to me like a fairly clear 'Air Safety' focus. Regulation and the rest is how it delivers the Air Safety.

Inter-service bickering - not sure how that affected the events that led to Haddon-Cave and the MAA. However, there were certainly big politics played by the RAF in the aftermath.

We now have an allegedly independent regulator whose head, according to its own internal rules, has to be a three star with aviation command experience - neat. That would be an RAF officer then then. Has been ACAS twice in a row now. And this for an organisation that was brought about by an inquiry into the failings of the MoD' airworthiness management systems that were devised and led by senior RAF officers. Go figure.

My preference (not that it matters in the least) would be for the MAA to be aligned with the rest of the Defence Safety boards (nuclear, explosive, ship, etc) and headed by a two star civilian brought in from outside the MoD to encourage fresh thinking and transference across all areas of Defence safety management. Honestly, I'm not sure that 'Air Safety' is any more demanding than nuclear safety, or any of the other safety management areas.

Oh, and I'd take the accident investigators out of MAA, relocate them into the AAIB, and require all three Commands to provide properly trained and accredited investigators to that organisation. Not expensive and can provide a very effective organisation. (The FAA did it for many years).

Not that any of that is going to happen any time soon, but always nice to see an open, polite and interesting debate taking place.

Best Regards as ever to all those actually contributing to safer military aviation,

Engines

[A and C]

The CAA is not funded by the government, it is funded by the fees it charges the industry................ And it feels like my company is funding most of it !

[Splash1983]

I stand corrected, my apologies you are absolutely right.

[dervish]

So can anyone say what part the MAA plays in fitness for purpose? I only ask because IIRC this caused confusion at an inquest. Can't recall which one.


Engines. Really good post sir.

[Chugalug2]

Yes, really good post Engines, thank you. I'm afraid that my distrust of the MOD regarding suborning of the Regulations and the subsequent cover up, would not enable me to have confidence in any Board that came under its umbrella though. I am now starting to worry about Nuclear, Explosives, and Ship Safety, but one thing at a time perhaps. ;)
One thing that you mentioned confuses me though, ie:-
I'd take the accident investigators out of MAA, relocate them into the AAIB, and require all three Commands to provide properly trained and accredited investigators to that organisation
Why on earth should Air Accident Investigators be within the MAA in the first place? As soon as we have yet another airworthiness related Military Air Accident, will we have Investigators employed by the Regulatory Authority responsible for that Airworthiness investigating it? How does that work, other than very badly?

Splas1983, this is all about Flight Safety (or Air Safety if you insist). It is also all about independence, the lack of which led to the "malaise that befell certain IPTs" and a whole lot more.
As for SQEPs (who invents this dross?), the MOD used to be awash with them, and very "Q" and very "E" every man jack of them was! It sacked them, or at least the ones that would not obey illegal orders to suborn the Regs. That is what must never happen again. The MAA as it exists now, together with the MAAIB, cannot ensure that it won't.

[Engines]

Dervish,

Hope I can help a bit here. 'Fitness for purpose' or 'fit for purpose' appears all over the MAA regulations set, in a number of contexts. Personally, I think it's a bit of a vague phrase, and used too liberally, probably because the politicians started appropriating it. I have a sinking feeling that the MAA probably thought it would look jazzy in the regs.

But to address a very good point you made - when looking at whether an aircraft's design (or a modification) meets operational 'fitness for purpose', my feeling is that the MAA regs have not much to offer. There is one clear link to the phrase in a recent update to 00-970 that includes the following:

Def Stan 00-970 is not intended to provide requirements to ensure the fitness for purpose of Type Designs or Major Changes.

Here's my take. It's probably wrong, but here goes anyway. When assessing a project, I put requirements into three (probably overlapping) bins:

1. Pure 'air safety' - the 00-970 stuff
2. Fitness for purpose
3. Operational effectiveness

To illustrate the idea, here's those three 'bins' applied to requirements for a new radio:

1. Pure air safety - does it catch fire? Does it fall out of the aircraft and kill someone? Does it irradiate users? EMC, Etc.
2. Fitness for purpose - can it be used by the aircrew without spending excessive time heads in? Does it clearly tell the user what it's condition and state is? Can it be maintained? Is it reliable? Does its basic performance meet the requirement (range, clarity, etc) Lots of HMI stuff here.
3. Operational effectiveness - does the HQ/crypto function work? Does it meet operational requirements for coalition/joint ops? Will the OEU accept it for service?

Like I say, these three may overlap, especially the last two, but I found that they help project teams work out the boundaries between the ATEC ITE folk and the OEU. They also help build a good requirements set, which is the foundation of any project.

So who's responsible? My call is that the project team are responsible for delivering a product to the user that is 'fit for purpose' as defined in the requirements PLUS (important point) any other aspects that they could reasonably be expected to apply to the job. (After all, they are supposed to be the procurement professionals, right?). And they're accountable to the user for doing this.

The Duty Holder is then responsible for accepting the system. Or rejecting it. Once accepted, the user maintains that 'fitness for purpose' via their CAMO and aircrew and personnel training systems.

In both cases, they are required to apply the relevant MAA regs while they discharge these responsibilities.

Now, does all this actually happen all the time in the real world? That's the big question, to which I don't have the answer.

Hope this helps a little, best regards as ever to all those reading these big books,

Engines

[Engines]

Chug,

Saw your post after I'd posted my last one - sorry.

We're loudly agreeing on one point. The accident investigators should never have been put in the MAA in my view. Haddon-Cave made a passing reference to how the RAF did accident investigation, made a number of incomplete and inaccurate statements about the other services and then produced a wholly unrelated recommendation. That then got hijacked into the MAA 'land grab'.

I will gently differ from you on ownership and independence. The MoD has a duty to endure the safe operation of its systems, and that is properly discharged via what was called the Defence Safety Board, which is where the nuclear and explosive safety boards (e.g. the old CINO) used to report into. MAA should have plugged straight into that.

My concern has always been that making the MAA a three star reporting directly to S of S was an overreaction to Haddon Cave, that was not required and gave the MAA a level of 'heft' it didn't actually need.

True and complete independence is always going to be a problem - 'who watches the watchmen'? The MAA's own Safety Advisory Committee is supposed to 'challenge' the MAA, but looking at it's composition (Chair is a retired Air Marshal), it's doesn't look as independent as it might - just too much hefty blight blue stuff around for my comfort - but I'm probably biased.

Best regards as ever to all those who damn well care,

Engines

[dervish]

Chug

Interesting that on the MAA website it defines "independent" as "external to the MoD."

Military Aviation Authority | MAA Safety Advisory Committee (http://www.maa.mod.uk/about/safety_advisory.htm)






Engines

Thanks for reply. Something to ponder. Thinking about it I believe it was the C130 IPTL who stated in court he didn't know how to achieve fitness for purpose or who was responsible. Glad to be corrected if wrong.

[thefodfather]

It's an interesting discussion as ever, although starting to creep away from original Just Culture question.

I'd just like to come back on a few points. Firstly, regarding Splash' comment about Air Safety, my understanding is that Air Safety = Flight Safety + Airworthiness + All the other new MAA stuff. I remember when DASC was formed it was all about Aviation Safety = FS + AW, but whilst it was a nice idea the reality was somewhat different.

In terms of independence, perhaps a radical approach is for the European Defence Agency to assume an EASA type role, at least in terms of airworthiness.

Finally, to come back to Just Culture. Normally, it is considered in the personal sense but I think more needs to be done to consider Just Culture in the organisational context. When organisational failings are identified then there should also be a way to hold parts of an organisation to account for deliberately breaking rules.

Sorry, too many points in one message but hopefully you get my drift.

[Chugalug2]

dervish:-
Chug
Interesting that on the MAA website it defines "independent" as "external to the MoD."

I see that they are referring not to the MAA itself, but to their Safety Advisory Committee, which as has been pointed out already by Engines is headed by a retired Air Marshal! I seem to remember that the MAA used to trumpet itself as being independent once, perhaps pennies are beginning to drop even there?

Engines:-
'who watches the watchmen'?
The $64,000 question of course. I would merely point out that when they are Regulators and Investigators they may have have less compunction about enforcing Regulation and performing stringent Investigation when it is not directed at their employer.
It is that simple, and the mess that is UK Military Airworthiness and Air Accident Investigation can be traced back to that one factor. Perhaps Explosives and Nuclear Devices have their own ways of discouraging messing about with. As to ships, they seem to be much in the news recently and, as one who used to disgrace himself while on a Paddle Steamer ride around Bournemouth Bay, I am in no position to comment either on their seaworthiness or fitness for purpose. It may of course just be the difference between Air Marshals and Admirals...