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Near miss at KMSP - 14th June 2023

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Near miss at KMSP - 14th June 2023

Old 3rd Jul 2023, 14:46
  #21 (permalink)  
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Originally Posted by ATC Watcher
Just Culture , or its new name " Safety Culture" does not apply after an incident or accident. It is there only for prevention , by basically removing accountability for individuals reporting their own incidents that would not have been reported otherwise, so that we learn from them to improve the system . It does not apply after an incident or accident has occurred which is the case here .But the original principle of Just Culture as defined by Prof Sidney Dekker is that focusing on the operator rather than looking for systemic issues is a normal management reaction to protect themselves from accountabilty.
Just Culture - and I don't know of any moves to change the name to Safety Culture, which is a separate, and much wider topic - seems to be a widely misunderstood concept without a universally accepted definition. Whilst it seems commonly to be viewed as little more than 'if you report something, you won't be blamed for it', for me, it is a far more nuanced concept which involves a balance with 'norms' of behaviour. The best definition that I have seen comes from Eurocontrol which says a just culture is one in which 'frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated'. Applying this definition means that actions taken in any undesirable event must be evaluated against a range of other factors, and it can be (and should be) applied after the facts contributing to a serious incident or accident are understood. It is not quick and easy to establish a Just Culture, and relies on the behaviour of an organisation at all levels to follow principles which meet whatever definition the organisation chooses to adopt - not just once, but at every opportunity.

A finding of an investigation in a 'Just Cultured' organisation may well be that an individual's behaviour does not meet that which would be expected, in which case some form of individual action is necessary. This does not mean that the problem is then fixed, because it would be necessary to investigate why 'the system' allowed the individual to work when their performance is inadequate. This is not an easy thing to have to deal with because in the most extreme case it can mean the end of someone's career - it is a sad fact, but out performance often deteriorates with age (although experience can often mitigate this deterioration, but that is another topic in itself) - but surely for 'the system' to remain professional, this may be necessary.

More usually, if the performance level of one or more people is not considered to be adequate for some reason, retraining or refresher training is often cited as the corrective measure (and this seems to be the course being followed by the FAA)....and then we can relax because the problem has been fixed. But do we know the quality of that training....or the relevance of the content?

Unfortunately, the value of training, whether resulting from an incident or a routine training programme, can be very limited. Some organisations can spend a small fortune on training, and get little, or even no, value for that expenditure. What is worse is that sometimes, an organisation has little or no understanding of how valuable or useful the training that they send their people on actually is - but, at least, they can say they've taken action following an incident or tick a box to say that they train their people. Until the effectiveness of actions taken to mitigate a risk or weakness is assessed, we cannot say whether or not the problem has been fixed - but that can't happen until long after the triggering event and rarely gets the headlines of the original event. So - how do we know how good the system is?
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Old 3rd Jul 2023, 21:37
  #22 (permalink)  
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@ Equivocal :yes, yes, Just Culture is part of Safety Culture which is now the new name we all use in ICAO as "just culture" became too limited. I was being brief and trying to explain things in 2 lines in here .
Fully agree that people use Just culture without knowing what it really ,means.
For those of you who want to dig a bit more into the subtillities of the subject I suggest this document which is rather well done . https://www.icao.int/NACC/Documents/...%20Process.pdf
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Old 4th Jul 2023, 16:13
  #23 (permalink)  
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'Kulcha' change?

How about a kulcha changer? Every misuse of 'on the go' and suchlike phraseology gets a name and shame mention and you tip five bucks in the cookie jar by the pilot or controller involved? It would raise millions for charity or FAA improvements.

Just examine LiveATC tapes with Artificial Intelligence voice recognition and voila!

Some university studying safety culture would be able to do this as an easy fact gathering exercise to quantify actual misuse, rather than the hand wringing here in these forums. As a bonus, you could clearly identify all parties requiring further attitude training, swiftly and cheaply, and benefit the entire industry and the travelling public with improved safety.
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