'Just Culture'

[ATCNetwork]

Curious to know what you all think about this 'just culture' that is being introduced.

http://213.218.170.40/NewsItem-25329.aspx

Are you willing to report those incidents which nearly happened or would you be more worried about the consequences?

[SINGAPURCANAC]

Just culture- Great idea
But it doesn't work everywhere.
And never will work.
Return to the starting point.
Culture.
Some places don't have it.
regarding EC and IFACTA,they just doing this. Meetings.I haven't seen where last meeting were held. It might be Funchal, Stromboli,Antalia,Lesbos,St.Stefan,Dubrovnik....

[Spitoon]

Essentially,it's been in place in the UK's Mandatory Occurrence Reporting (MOR) scheme for many, many years. How it works and how much people are prepared to report 'that was nearly very nasty' type incidents depends on the way that the reports are handled....and you only find out after experience.

In the UK MORs normally go through unit management before they get to the CAA. At one unit I worked at the manager would do everything to stop the report going further - even within the company - and always looked for who to blame for the incident, typifying almost the reverse of a Just Culture. Fortunately the UK scheme allows you to submit a report directly to the CAA in confidence and my experience of the way that the CAA handles the reports is nothing but positive. I have seen potential problems resolved through such reporting long before 'the incident' occurred.

It's all down to the people involved.

[climbwithagoodrate]

Don't confuse 'Just Culture' with 'No Blame Culture' - they do exactly as they say on the tin. In a 'Just Culture' if there is Blame to be apportioned, then it can/will be. In a 'No Blame Culture', well...

[Mr. Pig]

Anyone interested in exploring Just Culture would do well to consult the work of Prof. James Reason or Dr. Sidney Dekker. What follows is loosely based on their research (please excuse me if I seem a little pointy-headed!).:8

Just Culture is a little more involved than some of us may believe. Nevertheless, it is actually fairly straightforward: it is about establishing a set of preconditions for any high-reliability organisation (including ATC) to function safely. Yes, it is about wider reporting of safety threats; no, it is not simply a set of prescriptive rules for incident reporting. You can't just take a chunk of it and weld it on to an organisation or its procedures. There are already rules which demand that all occurrences are reported in the interests of safety; yet these rules are sometimes ignored.

By its very nature, culture refers to a set of shared beliefs, values & norms - in this case around the issue of safety - held by a group. We may refer to such things as "management culture", or "team culture" for example. Therefore, the safety culture of an organisation is the set of values etc. which determines the safety-based behaviour of the members within that organisation. To be described as a "culture", these values must be reflected by all members.

A "reporting culture" is an essential part of just culture. Individuals should be able to communicate their safety concerns freely, and without fear of punitive action (unless warranted). From a human factors standpoint, Just Culture is about allowing that humans will continue to make errors, but not all of these should warrant punishment - the application of which hinders accurate reporting. Accurate safety reporting will be most effective only when all parties have a shared purpose for gathering such information. Yes, this may require a bit of a "leap of faith" in some units/companies. Nevertheless, as those involved in aviation safety, surely we have a duty to give the subject of Just Culture a thorough hearing.

[Stampe]

My airlines management advertises itself as having a "just safety culture".They are absolutely correct any incidents investigated are "just the pilots fault".The body corporate cannot possibly have any failings in its operation.Aviation safety after years of improvement is now headed in the wrong direction and accelerating.We have a very weak regulatorwith the CAA being funded by the the operators whom they are meant to be regulating.I fear for the future of our once proud industry :ugh:

[airac]

What about:-
An ATC service is provided for the purpose of:
a) preventing collisions between aircraft in the air;
b) assisting in preventing collisions between aircraft moving on the apron and the
manoeuvring area;
c) assisting in preventing collisions between aircraft and obstructions on the
manoeuvring area;
d) expediting and maintaining an orderly flow of air traffic.

It all went down hill when they started giving people 'oligies':eek:

"just safety culture".:mad::mad::mad:

Why can't we be left to just get on with the job.

It now takes months to get a "New and Better " bit of kit up and running because we now have to write a tome on Which way it is " Newer and better " and what we will do if it goes wrong compared to what we would do if the present system went wrong , ETC, ETC, ET bl00dy C .:ugh:

The MOR system will suffice it aint broke why fix it:*

If it does come in then I hope the :8 who came up on this revalation gets strung up by the B@lls .

NURSE MORE WINE:ok:

[skydriller]

"Just safety culture" could also be termed "UnJust safety culture".

Just Safety Culture is all about taking the reponsability for any incident away from a corporate or collective responsability and placing that responsability directly onto individual employees. The idea is that if you recieved training about something from your company and then you do something wrong you were trained for, you will be blamed, and probably disciplined...

Fine, you say.... Problem is that doesnt really stack up well with the whole "chain of events" which usually leads to an incident. Also, if you screw up without any incident resulting, where is the incentive to report your screw up if you know you will be held responsable for screwing up?

I see a thread on this page asking if ATC is being dumbed down, with comments about "one way" to do something. Just culture at work...

Regards, SD..

[Spitoon]

Just Safety Culture is all about taking the reponsability for any incident away from a corporate or collective responsability and placing that responsability directly onto individual employees.skydriller, I feel that you - or those that set your environment - are grossly misunderstanding what the Just Culture concept is about. When it is working effectively it is, in reality, quite the reverse. For example, where there is an organisational weakness individuals should be able to raise the issue without fears.

But if an individual makes an error that is of their own making, perhaps after disregarding the relevant procedure, then surely that individual must bear some responsibility for their actions, n'est pas? You appear to suggest that whatever the individual does - be it right or wrong - if it all goes wrong then the organisation must bear the responsibility (please note that we are not talking liabilities here).

The MOR system will suffice it aint broke why fix itIn my view the MOR scheme (which is only a part of what might form a Just Culture) isn't broke - but many ANSPs and States have not had an MOR scheme in the past. Any such scheme must bed in whilst trust is (hopefully) developed in its operation. And, as I mentioned earlier in the thread, it's going to be down to the people involved in the reporting scheme to make it work effectively.

[eyeinthesky]

Airac:

The spirit, if not the exact words of your post reminded me of someone, but it took me a while to remember who. Now I do. He said:

Quote:

"When anyone asks how I can best describe my experience in nearly 40 years at sea, I merely say, uneventful. Of course there have been winter gales, and storms and fog the like, but in all my experience, I have never been in any accident of any sort worth speaking about. ...... I never saw a wreck and never have been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort. You see, I am not very good material for a story"

Unquote

He was: Captain Smith, Commander of Titanic.

We all know what happened to him. Beware of your attitude taking you the same way!

[RustyNail]

"Just Culture" as mentioned before examines every aspect of an incident or abnormal event, not just looking at the controllers actions but also examining the companies procedures and management in an effort to prevent a reoccurance, exactly as it should work.

If the controller took some actions which led to an incident then they will of course be held to account, just as management will be if their procedures are poorly designed and had an impact on the incident.

In some companies where the investigations were purely "punitive" i.e. the controller is always wrong, find some way to blame them and then move on, it is more difficult to accept "just culture" because they (old management) cannot accept that their procedures or poor management could possibly lead to an incident.

until there is a shift in attitude some companies will struggle to adopt a just culture when it is still easier to lay blame on the controllers.

[Knackers]

James Reason sez that in order to have a safe culture you need a strong reporting culture, and in order to have that, controllers must be satisfied that there is also a just culture.

In Oz, controllers are required to report all errors and, from where I sit, that's exactly what they do. They're quite prepared to put their hand up and say "I've made a mistake", be stood down until its investigated, and accept what ever subsequent action. Which could be, in order, no action, counselling, a check, remedial training, etc.

If a controller doesn't report it, the fellow next to him/her will. It's not squealing, it's the culture that safety is paramount. I've heard of one case where a controller didn't report an error, was stood down and given other duties for 6 months, and had to submit a written application as to why he should be given his ATC privleges back. That would be a hard letter to write. It's simpler to report an error.

[Quokka]

If the reporting culture is inadequate, then the statistics will not reflect the true situation.

If the statistics don't reflect the true situation, then the Systemic problems aren't being identified.

If the Systemic problems aren't being identified, then they won't be solved... and all the complaining in the world won't change the environment you work in if your Line Manager says... "Problems? What problems? There are no problems", because he has an e-mail in his hands that says that there have been no reports, mandatory or otherwise, that reflect the situation that you describe.

[Spitoon]

If the statistics don't reflect the true situation, then the Systemic problems aren't being identified. I think we are in danger of making too many assumptions here - or at least going beyond a reporting/just culture. Having a good reporting system will make the organisation aware...aware of where there are weaknesses in the system, where things are going wrong and, if there's a really good safety culture, perhaps supported by effective safety surves etc., where things might go wrong in the future.

What is done with this knowledge is another matter. It is possible to have good reporting but to fail to use it in an effective manner. Analysing the problems and identifying the systemic weaknesses...and then taking effective action to address them is a whole other matter!

On a slightly different point, I've seen people who believe that every failure is systemic, i.e. no one individual is at fault. For individuals working that environment it may be comforting to know that you'll never carry the can if things go wrong - but is that a Just Culture?

[SINGAPURCANAC]

How to deal with safety issues?- one manager asked .
we will apply SMS!- safety manager answered.
Ok! Nice. We spent a lot of money for your courses,now it's time to return it.
At first we should introduce "JUST CULTURE"
Culture , What?
It is just first step towards...
step or culture?
It is first step...
You are fired out. From today we will implement a brand new safety system.
NO TRAFFIC- NO SAFETY RELATED PROBLEMS!

[divingduck]

Singa...

Would you mind interpreting your last post for me?

Maybe I'm just stupid, but for the life of me I have no idea what you are on about?

[airac]

eyeinthesky.
I can only assume, from your somewhat weak analogy that you too blame
poor old Captain Smith.
I wonder if your "Just Culture”, that you appear to be advocating, had it been around then, would have come to the same conclusion.

I am not and never have been against improving safety and resent any inference to that end.
What I am against is the system where audits are the order of the day and new equipment cannot be bought into timely service for no logical reason.
However thank you for your concern.

[Spitoon]

It all went down hill when they started giving people 'oligies'

"just safety culture".

Why can't we be left to just get on with the job.

It now takes months to get a "New and Better " bit of kit up and running because we now have to write a tome on Which way it is " Newer and better " and what we will do if it goes wrong compared to what we would do if the present system went wrong , ETC, ETC, ET bl00dy C .

The MOR system will suffice it aint broke why fix it

If it does come in then I hope the who came up on this revalation gets strung up by the B@lls .


airac, I'm assuming that you're from the UK because of your extract from the books and reference to the MOR scheme.

The problem is that in the UK there is a fairly good and just safety culture in most ATC units and in the CAA. The MOR scheme, for example, has for the most part been managed by sensible people with a good understanding of how to use the information collected to improve overall safety rather than to apportion blame. Elsewhere the same very definitely cannot be said. The work going on across Europe now to develop a good and just safety culture is to try and inculcate a similar level of maturity to that which exists in the UK and a handful of the other states. Sadly, setting a few rules and then saying get on with it cannot deliver a maturity that has evolved over, for example in the UK, 30+ years of experience and for most of that time sound management.

Where I would agree with you completely is the way that ATC safety cases are being handled by the CAA. Here we seem to have a culture that essentially weighs the documentation before even considering the content. I have seen people from the CAA who have insisted that the safety case be done the same way as NATS (even though it's not coming from NATS), rejected paperwork because of a minor administrative error (OK, I grant you that it should not have got through but I tend to think that a date not updated in a page footer of one chapter is not particularly major sin) and comments on submitted documents such as 'this is not acceptable' without any hint of why. Rarely have I seen constructive comments on the safety arguments presented. To be fair, it depends very much on who you deal with in the CAA. But generally we seem to be going way overboard on the safety case thing with very little apparent benefit.

[airac]

Spitoon Your assumption is quite correct Re the UK (Location is a bit of a give away, but I’m just being picky there), also you have grasped what my original response was meant to convey.

Whilst we are on the subject or to stray slightly off the subject, the on going saga of ATSOCAS has taken yet another turn. Apparently the good people in charge have declared that the revised procedures for ATSOCAS be published in May 2008.
ANSPs will then be given 6 months to train for introduction of the new services, which is planned for Mid January 2009. The timescale allows for 2 months June & July for the production of training plans and their approval by SRG followed by August - Mid January for training.
A reasonable request? I don't think so, indeed the Good chap at an airfield situated to the east of Brum, has I believe, been tasked with consulting with other non NATS units, to seek a consensus as to the reality of the proposed time scale.
My point being, if its that imperative to introduce the scheme why can't SRG produce a generic training plan for all the units concerned this would , back to the original subject, prove that they (SRG) are actively aiding ANSP's ,instead of appearing to increase the already massive paper trail.

[Spitoon]

airac, just to keep going off at a tangent, where does your info on ATSOCAS come from? I've been waiting to see the final Comment Response Document from the consultation - but there doesn't seem to be one yet......

As for whether a training plan can be produced in two months - who knows until we can see what the finalised procedures look like. Who can tell whether August (assuming that the training plans are approved that quickly) to mid-January is long enough to do the requisite training.

I agree with you that this all seems a bit rushed, particularly as about two years seems to have been wasted after the latest prompt to review the procedures before the CAA got around to doing anything.

As a knee-jerk reaction I could see some units with the option simply deciding not to provide services outside CAS so there would be no need to do any of this training malarky - still, if it's good enough for ScATCC..... And I guess that would be marked up as a success for the CAA.

I'm a bit dubious that one could develop a generic training plan for many aspects of unit procedures, but for a change to national procedures I don't see why not. Frankly, unless you have an especially dense bunch of controllers on a unit I can't see why the training needs to be anything more that a briefing on the differences between old an new procedures.

Oh well, I can't get too wound up about it because it's all going to change again soon when EASA starts setting the rules, and air traffic control (regardless of what anyone chooses to call the service) is going to be persona non grata.

Ho hum....I must be getting cynical in my old age.

[SINGAPURCANAC]

To go further with interesting cases around the World.
Friend of mine living and working in Japan. he sent me an e-mail yesterday with part of original text from Japanese daily newspapers, english language version of course.
Japanese court sentenced one ATCO 12 months plus 3 years of suspension and OJTI ATCO 18 months plus 3 years suspension. They were working on Sector in ACC when air miss occurred a few years ago. They gave wrong descent instruction but STCA and MTCA didn't work properly. Due to lack of investment. Some software malfunction. Everybody knew for it but no one change it.
There are more countries in the world without or with undeveloped safety culture in aviation business than countries with correct approach.
My research told that only Denmark, Oz, NZ ( sorry if I omit someone,but it is not intentionall) have Safety Culture.
@ Divingduck ,
If you again need an explanation or translation,just tell me ,i will arrange something for you.

[discountinvestigator]

Just culture helps with bringing the organisation to account, not just the ATCO with the microphone. You pushed the button, it is your fault.... I do have experience in this area and I am providing evidence to defend ATCOs in various cases at the moment.

There are many safety cases around in ATC that are inadequate. The usual failings are those of inadequate risk criteria and risk optimisation criteria, poor hazard identification carried out by unqualified staff, poor quantification with that 5x5 matrix that does not stand-up to any real examination for big ATC related accidents, poor human error analysis, poor equipment reliability analysis, poor procedure design mistake analysis as well as poor risk monitoring. Don't even get started on the lack of safety cases for current operations and ignoring capacity increases as a change to the system.

The barrister's opening question to the author of the safety case of please outline your psychological, engineering and risk management qualifications to be the signatory of this document is a good one.

Beware public expectation!

[Spitoon]

There are many safety cases around in ATC that are inadequate. The usual failings are those of inadequate risk criteria and risk optimisation criteria, poor hazard identification carried out by unqualified staff, poor quantification with that 5x5 matrix that does not stand-up to any real examination for big ATC related accidents, poor human error analysis, poor equipment reliability analysis, poor procedure design mistake analysis as well as poor risk monitoring. Don't even get started on the lack of safety cases for current operations and ignoring capacity increases as a change to the system.It sounds like what you would like to see is the 100% best safety case possible - right now - today.....and done just the way that you would do it.

But how will that be achieved? People have to learn the skills that will result in good and well documented safety arrangements. This isn't going to happen overnight, it will take time, and a good number of other factors will come into play also.

But what the 'give me everything today' approach is doing is forcing people to try and do things that a book/auditor/condultant tells them they should be doing without understanding why or what the benefit is. Surely it is better to establish the principles in a way that makes sense and then, over time, to develop the processes where a clear benefit can be identified.

It might make you feel good to bandy phrases like 'inadequate risk optimisation criteria' around but unless those to whom you are preaching understand why you think there is a better way you are wasting your breath and, possibly, creating confusion in the minds of those who have yet to learn the basics.

Yes, the world is not perfect but if we want something useful at the end of all this we need to remember that you can't go for the best on day 1 and not everyone is at the same level of maturity as others. This applies to the establishment of a Just Culture as much as to pretty much every other element of good safety management.

As forThe barrister's opening question to the author of the safety case of please outline your psychological, engineering and risk management qualifications to be the signatory of this document is a good one.One might well query said barrister's qualifications for judging the quality of the response. But you are right - sadly most of us would be unable to satisfy the barrister. Certainly not in the way that you can. :rolleyes:

[ATCNetwork]

IFATCA, FSF and IFALPA issued a joint press release on the Japan case this morning

Front line operators and Flight Safety Foundation criticize the conviction of two Air Traffic Controllers in Japan

http://www.atc-network.com/NewsItem-25459.aspx

[SINGAPURCANAC]

@ ATC Network,
It is maximum. Strong press release, they do not agree with, it is unacceptable for aviation professional associations, but ATCO and OJTI are still in prison. And they will stay there.
IFATCA has no any power other than to organize meetings at expensive and exotic places.
Do you remember case with Ukrainian ATCos?:ugh:

[ATCNetwork]

Yes but I also remeber a case over Zagreb 1976 where something was done. I'm not saying IFATCA can resolve this but it is a start to at least make such a statement.

Better than sitting back and saying '**** happens'.

[SINGAPURCANAC]

To be honest regarding Zagreb case,
ATCO( executive) was sent to jail first,but latter on when State ( ex SFRJ) realized that it would pay to insurance company damage( case is still in court) they released him from prison,and immediately return him to operational duties. Why? because-If he is guilty-than state is also guilty and state must pay for damage. I don't know and there is no comments here that IFATCA has done anything.
By the way,planer and assistant work( maybe some changes in recent times) in Zagreb,while executive died a few years ago in Belgrade, RIP.

[ATCNetwork]

But should we sit back and do nothing? Or at least kick up some noise?
If i was a relative of the Japanese controllers I would hope someone was at least making some noise.

[SINGAPURCANAC]

I haven't said that we (ATCOs) or IFATCA and unions should sit in chair and doing nothing. I just said that IFATCA had no really power to do anything serious. From my point of view the strongest position lies in ATCOs hand itself.
Read your contact seriously,do your homework before signing contract, find relevant infos about company and authorities ,and the last one you always should aware that sh... happens and in such cases only HIS MAJESTY(if you are religious) may help.

[Spitoon]

Read your contact seriously,do your homework before signing contract, find relevant infos about company and authorities ,and the last one you always should aware that sh... happensOK, now I'm confused. What do you expect the contract to say?

[SINGAPURCANAC]

My mistake,
I didn't explain it exactly. Point lies at the last part of sentence. Collect infos about company and appropriate authories.
It is always possible that problems(safety related) could happen. It is just question is it in your shift while you are logged in or you are log out. If it happens than it is better to work where Just culture or adequate SMS and critical stres management exist rather than ultra developed and sofisticated Japan.
I hope that now is Ok,

Best regards,