Shoreham crash and "Just Culture"
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Shoreham crash and "Just Culture"
This week, the High Court is expected to rule on whether the police may have access to key material, including flight deck voice recorder, to enable them to continue with their criminal investigation into last year`s disaster at Shoreham Air Show. Police access to confidential AAIB information is bound to ignite the controversial issue of "just culture" and criminalisation in air accident investigations.
As the AAIB report is not expected to be released until 2017, it would seem that justice impatient, needs to be served earlier.
As the AAIB report is not expected to be released until 2017, it would seem that justice impatient, needs to be served earlier.
Below the Glidepath - not correcting
Chronus,
There's already a detailed discussion underway in this particular area on the Military Aviation forum here:http://www.pprune.org/military-aviat...m-airshow.html
Some of that discussion is even reasonably informed...
There's already a detailed discussion underway in this particular area on the Military Aviation forum here:http://www.pprune.org/military-aviat...m-airshow.html
Some of that discussion is even reasonably informed...
Just Culture Definition
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated
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The debate, which I thought may be worth encouraging, was whether the interest of justice prevailed over confidentiality.
The disclosure in the ‘interests of justice’ principle is enshrined in European law, under Article 14.3 of EU Regulation 996/2010 (the Regulation). The Regulation reinforces the principles of ICAO Annex 13 which provides for international standards and recommended practices in relation to air accident and incident investigations, the primary objective of which is to prevent future accidents and incidents and not to apportion blame or liability. Inevitably, while the official air accident investigation and any criminal investigation are intended to remain entirely separate, the paths of the two investigations inevitably cross on numerous occasions throughout the process and are driven by entirely different agendas.
The fundamental principle which should underpin all accident and incident investigations is ‘just culture’. As Recital 24 of the Regulation clearly states, civil aviation systems aim to ‘promote a non-punitive environment facilitating the spontaneous reporting of occurrences’. Yet some argue that increasing pressure and, to some extent, public clamour to attribute blame and immediately criminalise investigations, as was seen in the aftermath of the Germanwings tragedy when the French public prosecutor was prominent in early public announcements, might be harmful to and fetter future accident investigation and reporting.
It therefore boils down to a very precarious tight rope balancing act.
The disclosure in the ‘interests of justice’ principle is enshrined in European law, under Article 14.3 of EU Regulation 996/2010 (the Regulation). The Regulation reinforces the principles of ICAO Annex 13 which provides for international standards and recommended practices in relation to air accident and incident investigations, the primary objective of which is to prevent future accidents and incidents and not to apportion blame or liability. Inevitably, while the official air accident investigation and any criminal investigation are intended to remain entirely separate, the paths of the two investigations inevitably cross on numerous occasions throughout the process and are driven by entirely different agendas.
The fundamental principle which should underpin all accident and incident investigations is ‘just culture’. As Recital 24 of the Regulation clearly states, civil aviation systems aim to ‘promote a non-punitive environment facilitating the spontaneous reporting of occurrences’. Yet some argue that increasing pressure and, to some extent, public clamour to attribute blame and immediately criminalise investigations, as was seen in the aftermath of the Germanwings tragedy when the French public prosecutor was prominent in early public announcements, might be harmful to and fetter future accident investigation and reporting.
It therefore boils down to a very precarious tight rope balancing act.
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There were several go-pro type cameras installed - at least one of which as I recall from what has been said by the AAIB in an interim statement had a good view of the instrument panel/controls.
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Just Culture Definition
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated
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Some of the posts here seem to be pushing more of a no blame culture - not a good thing.
A just culture sits between blame and no blame. Errors, mistakes etc are tolerated and looked upon as opportunity to learn. However, if someone wilfully violates a clearly defined system then they can prepare to face the consequences.
You cant hide behind a 'just culture'. If serious misconduct is evident, we can expect police intervention. Pilots failing alcohol screaning will be a good example........!
A just culture sits between blame and no blame. Errors, mistakes etc are tolerated and looked upon as opportunity to learn. However, if someone wilfully violates a clearly defined system then they can prepare to face the consequences.
You cant hide behind a 'just culture'. If serious misconduct is evident, we can expect police intervention. Pilots failing alcohol screaning will be a good example........!
No answer the OP.
After 30 years in aviation, I am yet to see this "just culture".
It is a rather sick statement that needs burying in the archives of aviation.
There is no just culture. If the management want a certain decision / certain persons put in their place, it will happen regardless of the rights, wrongs, or the associated laws.
It's a bit like arguing life should be fair. If you want fairness, DO NOT work in aviation.
List of suggested banned statements:-
1. Safety is our No.1 priority no compromises.
2. "Just culture". So untrue it has to be in inverted comma's at all times.
3. We have the finest FRMS system in the world.
After 30 years in aviation, I am yet to see this "just culture".
It is a rather sick statement that needs burying in the archives of aviation.
There is no just culture. If the management want a certain decision / certain persons put in their place, it will happen regardless of the rights, wrongs, or the associated laws.
It's a bit like arguing life should be fair. If you want fairness, DO NOT work in aviation.
List of suggested banned statements:-
1. Safety is our No.1 priority no compromises.
2. "Just culture". So untrue it has to be in inverted comma's at all times.
3. We have the finest FRMS system in the world.
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I was involved in implementing the principle of Just Culture in a former life, it works relatively well in our so called "western culture " , but South of the 40th parallel and after 15 East , the concept slowly fade away to local reality.
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JC works relatively well for incidents , not so well when there are casualties around .JC principle is to encourage , even reward, incident reporting , and to be able to do so without fear of being blamed. It is not an " out of jail" free card .
Also JC as we know it in Aviation is not really fit for military operations, and I would dare to add , nor for an airshow accident. So using the term in here is somehow inappropriate I would say.
.
JC works relatively well for incidents , not so well when there are casualties around .JC principle is to encourage , even reward, incident reporting , and to be able to do so without fear of being blamed. It is not an " out of jail" free card .
Also JC as we know it in Aviation is not really fit for military operations, and I would dare to add , nor for an airshow accident. So using the term in here is somehow inappropriate I would say.
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Surely the correct procedure would be to let the accident investigation come to its conclusion, and if, as may be likely, some culpability is suspected, employ a court order to be given access to any evidence in the possession of the AAIB.
Anything more "pushy" could be held as interfering with/delaying the production of the accident report, which should overwhelmingly be the 1st priority.
Anything more "pushy" could be held as interfering with/delaying the production of the accident report, which should overwhelmingly be the 1st priority.
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Conclusions and the law
If a pilot knows he may not fly below 500' above a large group of people, except for take off or landing, and sees many more collected under his planned display area what should he then do?
If a pilot knows that such groups collect ever year should he undertake the flight?
If a pilot knows that such groups collect ever year should he undertake the flight?
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If prima facie evidence of wrongdoing, criminal activity, carelessness, malpractice, or indeed the exact opposite exists, it should be made available to investigators, no matter what the original reason for gathering or recording that incident. The very fact that people might modify their behaviour in response to the knowledge that everything they do is being recorded is telling in itself.
It appears that air display organisers and pilots have been playing a bit loose and fast with the rules for quite some years. So long as no one gets hurt and the public get to see an exciting display, its okay, right?
Well, no it isn't. The odds may be a million to one against a serious incident, but sooner or later that chance event happens, and without the additional safety factors built in by the rules, people get hurt. It is always a combination of factors and investigators need to be able to access all the data to arrive at the correct finding. That result may not be "fair", but it should at least be an accurate account of events.
It appears that air display organisers and pilots have been playing a bit loose and fast with the rules for quite some years. So long as no one gets hurt and the public get to see an exciting display, its okay, right?
Well, no it isn't. The odds may be a million to one against a serious incident, but sooner or later that chance event happens, and without the additional safety factors built in by the rules, people get hurt. It is always a combination of factors and investigators need to be able to access all the data to arrive at the correct finding. That result may not be "fair", but it should at least be an accurate account of events.
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The display line was well defined and the risk management of the display took into account the surrounding built up areas so that risk management cannot be called into question. Sadly that management did not account for spectators gathering in unauthorised areas outside the field precisely where those poor souls perished.
If it is proven that the pilot entered the manoeuvre too low/slow then it comes down to an error of judgement made by an experienced pilot in otherwise favourable conditions. Unless someone can prove recklessness or negligence on the part of the pilot.... a single error of judgement is hardly enough to convict for involuntary manslaughter.
Thankfully we don't have the attitude of some of the Mediterranean nations where the mentality is... 'If somebody dies - Somebody must pay'.
It is right and proper that relatives of the bereaved get answers to all their questions, but let the man be judged upon the facts... not by cheap newspaper headlines whipping up the relatives into a frenzy of revenge.
If it is proven that the pilot entered the manoeuvre too low/slow then it comes down to an error of judgement made by an experienced pilot in otherwise favourable conditions. Unless someone can prove recklessness or negligence on the part of the pilot.... a single error of judgement is hardly enough to convict for involuntary manslaughter.
Thankfully we don't have the attitude of some of the Mediterranean nations where the mentality is... 'If somebody dies - Somebody must pay'.
It is right and proper that relatives of the bereaved get answers to all their questions, but let the man be judged upon the facts... not by cheap newspaper headlines whipping up the relatives into a frenzy of revenge.
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Magplug, yes I agree stick to the facts. Those killed were not only "spectators gathering in unauthorised areas outside the field" - there were people going about their own business. It is this fact which probably opens the biggest can-of-worms. 
Personally, I'm not minded for an individual public flogging as there is enough evidence to say that display pilots crash on a fairly regular basis - it happens. It will be more interesting to understand the various slices of Swiss cheese contributing to this tragedy and whether any individual hole, or combination of, could have been reasonably foreseen.
Personally, I'm not minded for an individual public flogging as there is enough evidence to say that display pilots crash on a fairly regular basis - it happens. It will be more interesting to understand the various slices of Swiss cheese contributing to this tragedy and whether any individual hole, or combination of, could have been reasonably foreseen.
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there were people going about their own business.
I'm not sure what is being said here. In this country causing death through negligent or reckless behaviour is a criminal offence - are people suggesting that pilots should be exempt from this? If I drive at 60mph down the high street and then due to ice on the road I don't make the corner at the end, ploughing into a bus queue and killing people, the proximate cause of the crash may well have been the ice, but I will be tried for manslaughter or death by dangerous driving and probably convicted.
In driving at 60mph I would have exceeded the limits of my "display authorisiation" and in doing so in icy conditions with nearby pedestrians I would have shown a negligent/reckless lack of "carmanship".
If someone breaks the known rules, authorisations and limits of good airmanship and people die as a result I would expect a criminal prosecution. We don't see it happen that often simply because of the very unusual feature of this crash - the pilot actually survived.
But why should different rules apply to pilots than to the rest of the population?
PDR
In driving at 60mph I would have exceeded the limits of my "display authorisiation" and in doing so in icy conditions with nearby pedestrians I would have shown a negligent/reckless lack of "carmanship".
If someone breaks the known rules, authorisations and limits of good airmanship and people die as a result I would expect a criminal prosecution. We don't see it happen that often simply because of the very unusual feature of this crash - the pilot actually survived.
But why should different rules apply to pilots than to the rest of the population?
PDR
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"Detective Chief Inspector Paul Rymarz, who is leading the investigation, said: "The application is to enable Sussex Police to obtain access to legally protected material including cockpit recorders and footage, expert reports and some documentation."
The two judges who heard the application last week have reserved judgement.
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I'm not sure what is being said here. In this country causing death through negligent or reckless behaviour is a criminal offence - are people suggesting that pilots should be exempt from this? If I drive at 60mph down the high street and then due to ice on the road I don't make the corner at the end, ploughing into a bus queue and killing people, the proximate cause of the crash may well have been the ice, but I will be tried for manslaughter or death by dangerous driving and probably convicted.
In driving at 60mph I would have exceeded the limits of my "display authorisiation" and in doing so in icy conditions with nearby pedestrians I would have shown a negligent/reckless lack of "carmanship".
If someone breaks the known rules, authorisations and limits of good airmanship and people die as a result I would expect a criminal prosecution. We don't see it happen that often simply because of the very unusual feature of this crash - the pilot actually survived.
But why should different rules apply to pilots than to the rest of the population?
PDR
In driving at 60mph I would have exceeded the limits of my "display authorisiation" and in doing so in icy conditions with nearby pedestrians I would have shown a negligent/reckless lack of "carmanship".
If someone breaks the known rules, authorisations and limits of good airmanship and people die as a result I would expect a criminal prosecution. We don't see it happen that often simply because of the very unusual feature of this crash - the pilot actually survived.
But why should different rules apply to pilots than to the rest of the population?
PDR
There really are good public interest reasons for establishing exactly what happened, and, as far as possible, why it happened, even at the cost of not prosecuting someone who might have committed a crime, in all such cases. It is often more important that it does not happen again, than that someone is punished.
In merchant shipping we have seen the criminalisation of deck and engineer officers has been pushed by public opinion to absurd lengths - to the point indeed where two officers were held in jail in South Korea for two years because they had "caused pollution" when in fact a tug and barge had crashed into the side of their correctly anchored, correctly positioned, correctly lit, immobile, vessel.
Be very very careful of what you wish for. I strongly urge aviation people not to go down the path of encouraging prosecutions of flight deck and cabin crew members.
Last edited by Methersgate; 27th Jul 2016 at 15:10.
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Interestingly a semi-precedent has been set, albeit under Scottish law, though according to Lord Jones, not a precedent:
Scottish Court Orders Release of Sumburgh Helicopter CVFDR - Aerossurance
Scottish Court Orders Release of Sumburgh Helicopter CVFDR - Aerossurance