More Just Culture and More Regulation please!
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!