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Old 28th Oct 2013, 13:06
  #46 (permalink)  
A and C
 
Join Date: Jan 1999
Location: north of barlu
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Just culture and open reporting.

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.
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