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Just Culture

Old 25th Oct 2013, 16:50
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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!
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Old 25th Oct 2013, 16:52
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Originally Posted by MG
It's a while since I flew, but about 6 years ago I felt the need to submit a CONDOR. Whilst my name didn't (seem) to get to the stn cdr of the place concerned, my rank and 'experience level', shall I say, certainly was known. Tie those togehter and you get a very small pool of suspects. I trusted that system as I truly believed that it was there for all the right reasons, but I certainly felt let down and exposed.

I hope things are better.
A very similar thing happened to me.

I CONDORed a Senior Officer and got hauled through the mire as a result. That was a major factor in my taking my option and leaving the Service.

Just Culture my arse. The Service has never shown loyalty towards towards those percieved to be 'rocking the boat'.
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Old 25th Oct 2013, 19:10
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The concept of a just culture is one of those unattainable ideals, which represent the gap between theory and practice.
A just culture is not something you have; it’s like safety, it’s something you do.
Similarly, definitions of what should be done are not a great help, particularly where the managing individuals hold the definition, and where judgement is always with hindsight. Drawing a line is not important; it’s who draws the line (Dekker).

The key issue is not the submission of reports, but how they are handled by individuals. Will those who manage be free from bias; do they have and apply sufficient human factors knowledge in their judgements, do they have sufficient role and situation experience – including that of ‘error’.
Do the operators at the sharp-end have similar qualifications so that they can draw their own line, but in this instance in real time.

If the sharp-end can be provided with the means of ‘doing the right thing’ for the situation, context, and within the limits of human performance, then there should not be any need to judge individual performance after the fact. However, situations and human performance are never clear-cut, thus the managerial judgement must have similar provisions for ‘doing the right thing’.
This requires training and knowledge in the skills of human performance, primarily for the blunt-end, because if the sharp-end activities result in ‘crossing a line’, then it’s more than likely that management have accountability for ‘the line’ and many of the situational contributions to human performance.

Management should consider that there is no such thing as error. Instead substitute ‘variable human performance’ which might trigger an alternative way of thinking about people and safety in general. Then perhaps we won’t need to ‘create’ the concept of a just culture; instead use a new way of thinking about safety.

For staff college reading The ETTO Principle.
and
“… we must all be held accountable for our efforts to make the system safer”
.

Last edited by alf5071h; 25th Oct 2013 at 19:13. Reason: typo
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Old 25th Oct 2013, 19:26
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You have ruined Flight Safety with MAA

You must cut the process. Join up MAA inspections, standards visits, engineering QA, Command assurance visits....make the burden on the units less erksome.

It is a major factor in Morale being at rock bottom, along with remuneration being 20% less than 3 years ago, SDSR and NEM on the horizon and senior officers transferring pension wealth from juniors under the term 'transition arrangements'. Its no longer a way of life, its a mediocrely paid job with barely minimum wage for the hours we work and the responsibility we are asked to hold.

But I bet the process monkeys in our ivory towers click the score card 'green'.

So to answer the question, make half your Air Safety staff redundant, then we can actually get on with our real job. We at the coal face are not idiots, stop assuming otherwise and maybe we can start to regain this roadsmash of a system.

Rant over, Sir.
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Old 25th Oct 2013, 20:01
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What an interesting response from who I presume are RAF posters. In my experience the Fleet Air Arm have successfully operated a just culture for decades. The principle of allocate blame where it is honestly due and then move on, but more importantly learn from errors and encourage honest debriefing is a watchword in the FAA. It was never more stark than the difference between a FAA BOI and an RAF one. The former was independent and reported in weeks, whereas the latter could take years and was often manipulated up the command chain......did anyone mention chinook.

Last edited by Bismark; 25th Oct 2013 at 20:53.
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Old 25th Oct 2013, 20:08
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I really can't see how DAEMS is going to work...

- No trust in 'Just Culture'
- No time to submit reports
- Inviting outsiders to conduct OSIs will be frowned upon by Stn Execs

I hope I'm wrong!

LJ
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Old 25th Oct 2013, 20:27
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Ahhh, got those rose tinted specs on again shippers.....
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Old 25th Oct 2013, 21:02
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The concept of a just culture is one of those unattainable ideals
Not in most European airlines, it works perfectly well and pilots can stay truly anonymous if they want to. The management genuinely respect it too. Were you referring to just culture as a military ideal?
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Old 25th Oct 2013, 21:02
  #29 (permalink)  
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Having submitted my last post, I do believe that we (RAF) want a Just Culture and that we achieve that at Sqn level and, mostly, higher. I just think that the system is open to those who want to abuse it, usually through ringing up mates and having 'off the record' chats to find out things that they shouldn't. I suspect that was what happened in my earlier example.
So, in response to Bismark, I suspect that the RAF is no better, nor any worse than the RN.
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Old 26th Oct 2013, 07:12
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Angry

Is a Just Culture really a topic for the RAF Flight Safety Team to discuss on an open forum? It has already become a 'bitch feast'! Come on Wg Cdr Spry you must have thought this one through before you submitted your post. Oh I guess not. Did you really think you would get a big pat on the back from the Gp Capt for this? Get back to your real job and stop wasting time!!!!!!!!!!
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Old 26th Oct 2013, 08:10
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Is a Just Culture really a topic for the RAF Flight Safety Team to discuss on an open forum? It has already become a 'bitch feast'! Come on Wg Cdr Spry you must have thought this one through before you submitted your post. Oh I guess not. Did you really think you would get a big pat on the back from the Gp Capt for this? Get back to your real job and stop wasting time!!!!!!!!!!
Very unfair!
I don't think this thread is a bitchfest (yet) and I do think it can contribute to an informed opinion. What better way than to engage with the forum that people often turn to to vent their spleen?
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Old 26th Oct 2013, 08:26
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Is a Just Culture really a topic for the RAF Flight Safety Team to discuss on an open forum?
By its very nature, if it cannot be discussed on an open forum then it must have failed. There are some candid comments on here and nothing that can be regarded as a 'bitch-feast'.
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Old 26th Oct 2013, 08:29
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Since finally retiring I’ve taken a keen interest in two cases I think unjust, the Chinook and Sea King ASaC crashes. In both cases MoD continues to unjustly apportion blame. MoD support retired officers who publicly blame the Chinook pilots in the media. On Sea King, MoD openly blame a civilian for what they have determined was the most likely of the 3 contributory factors listed by the Board of Inquiry. (I’ve deliberately used “MoD”, not RAF or RN. The Army isn't blameless either.) In each case senior staff were allowed to judge their own case and evidence that would have “cleared” these people withheld from inquiries. I wish I knew more but the published evidence is very clear and it doesn’t indicate a just culture. If Wg Cdr doesn’t know this then he’s not doing his job. If he does, the original post is just a bloody wind up.
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Old 26th Oct 2013, 09:12
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Having completed my previous tour in the the newly form Duty Holder construct I can recognise many of the issues previously posted.

A Just Culture is very difficult to achieve, it is a question of proportionality and pragmatism. I can remember a number of cases that we had to advise the hierarchy as to what would be acceptable in the form of punishment, if any at all.

The Just Culture principle is taken very seriously within my specific area and whilst there is scepticism from the coal face the message is leaking through to others at my level.

The DAEMS system was devised to provide an independent investigation and audit facility for the just culture and links the fair and just model used by FS at a stn level to apportion any blame. I can vouch for the depth of these investigations as the buck doesn't just stop, the entire system is investigated and reported upon.

There are still issues that need to be addressed however. There are (albeit a minority) now in senior management that are destroying the shaky belief in Just Culture. This is frustrating because once confidence is broken it is difficult, if almost impossible to rebuild. The next one is that the process is too slow. A large stn like Brize can receive hundreds of DASORs a week, from the very trivial to Cat 1 AIRPROXs. There just aren't enough people in Air Safety to process all of these in a timely manner. One notable DAEMS investigation took over 6 months to conclude, leaving the individual concerned in limbo and the stn hierarchy floundering for a suitable course of action. The last one is access to ASIMS. Having ASIMS on the intranet is fine but for those deployed or just down route it would be far simpler to have a secure gateway to access ASIMS via the internet. Changes should be made to the form also to speed up the input but a broader discussion is needed on that.

Overall the system is there and working, those who comment that Air Safety staff need to be reduced really have no clue what it trying to be achieved. The Haddon Cave report was damning of the MoD and the culture that existed at the time. The world has changed and Crown Immunity from corporate manslaughter charges just doesn't exist. These very same Air Safety staff that need to be culled are there to provide the evidence to back up the Sqn/Stn Cdrs and the higher echelons when their decisions are called into question. The job needs to be done correctly without prejudice to Air Safety and if something or someone is compromising this then action needs to be taken, brushing stuff under the carpet is no longer acceptable.

We are a military organisation and risk is inherent in the frontline job. That said the bottom line is can the risk be reduce to as low as reasonably practical whilst looking at the operational necessity of completing the job.
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Old 26th Oct 2013, 10:26
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Where we currently are the RAF OSI team and our MEDA investigators work together to get to the root cause of the issues when required to.

A simple tool that needs no training in is called the FAIR model (used to be called the culpability slide/slope/chart), the only problem is there has been the odd time when great discussion has taken place to try and get a person over the 'line in the sand' with a view to some form of disciplinary action, which is obviously not part of Human factors and the 'Just Culture' theme.
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Old 26th Oct 2013, 16:11
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Around 2 years ago Spry I mentioned in a mtg with IFS that whilst the concept of Just Culture was developing across Defence (and developing well in some areas/specialisations) in others, like ATC, it was inconsistent. The whole thing is hugely personality dependent and, being in a position to see the data on a daily basis as I am, you can see the change in reporting levels within 2 weeks of a new SATCO arriving in post. Unfortunately, both positive and negative. The only thing with the meeting a couple of years ago though was that I distinctly recall one Group Captain asking me why Just Culture within ATC was lagging when we have 'Regulation and Policy that states that we shall have a Just Culture'. It was then that I related the old story of the reluctant pony at the watering hole. Sadly, he just didn't understand.

There are many reasons behind the problems but resolving 2 would go a long way to solving the whole problem. Firstly, education. As an organisation we need to fully understand the human source of error and its inevitability but also how we can manage that human activity on a day-to-day basis to get the most out of our guys and manage error. Our HF trg is well intentioned but, given its generic nature, it makes it harder for our people to apply the principles directly to their own roles. It then, slowly, becomes perceived as a box ticking exercise because the guys can't see the operational benefit. The second issue is resourcing, as has been mentioned earlier in the thread. To do this 'safety work' effectively we need additional resource, which means a bigger tail for the dog OR, it means getting the politicians to think long-term. Spend big on infra-structure etc for a couple of years but then you'll have a smaller outlay in the following years. There's a lot of real estate and sacred cows out there that we don't need.
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Old 26th Oct 2013, 20:00
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Sir,

Just Culture is inextricably linked to Open and Honest reporting, and vice-versa.

The problem that you have is that both are hard won and very, very easily lost and if you lose one, you lose the other.

- So long as ASIMS authors are being hauled over the coals by VSOs in front of their peers, you have nothing.

- So long as line managers choose to punish genuine HF errors so obviously linked to wider issues, you have nothing.

The list goes on...but not for this forum

The guys n gals on the shop floor are all for it, just sort the upper echelons out first.

Last edited by Uncle Ginsters; 26th Oct 2013 at 20:51.
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Old 26th Oct 2013, 23:22
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As stated previously, the only way to truly engender change is to eliminate those who blatantly disregard it.

Until the dinosaurs are extinct, you will still remain liable to be eaten.
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Old 26th Oct 2013, 23:41
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For this to work we need to trust those "in the chain of command". Very much like the "anonymity" of our posts here, any reporting or posting system only remains anonymous up to the point when someone feels the need to delve deeper and over-ride the pledge of protection. That is a clearly stated policy - and for sound reasons. Be careful what you own up to.
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Old 26th Oct 2013, 23:50
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I've edited my last post as this is a public forum, but in short the 'Just Culture' comes somewhere down the list of priorities these days if other factors can be seen to bring the Services into a bad light.

In those circumstances Im not sure being fair and /or 'Just' is the number 1 priority.

Last edited by AutoBit; 26th Oct 2013 at 23:56.
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