Just Culture
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Just Culture
Chaps, we're all being encouraged to submit reports under the umbrella of a "Just Culture", but a conversation I had at the recent FSO symposium made me wonder if we really believe we're living in such a healthy environment. I believe we are, but if there are any doubters out there, I'd be interested to canvass your opinions - remember, we're also a Learning Culture, so we should listen to people's concerns....over to you
Yours aye
Spry
Yours aye
Spry
The Just Culture depends on the agenda of the day. If the message can be shaped or used to support something that the wider chain can support then Just Culture works. If the message or event is deeply uncomfortable for someone in the higher echelons then the retribution can be brutal, even if someone is expressing an airworthiness concern.
I have known people to removed from post within a day for speaking out with a genuine concern, even if that person has documented and referenced all the supporting evidence.
It can be brutal at times if someone highlights something that can embarrass a star ranking officer.
I have known people to removed from post within a day for speaking out with a genuine concern, even if that person has documented and referenced all the supporting evidence.
It can be brutal at times if someone highlights something that can embarrass a star ranking officer.
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I think it is branch dependant (in the RAF anyway). I am impressed with the number of reports submitted by my stn's aircrew and feel that amongst those there is a real sense of 'just culture'. Compare that to my branch (ATC) where we are still stuck in the dark ages, personnel are genuinely concerned that if they make a genuine mistake the whole world will come down upon them.
No amount of mouth music from Cmd changes the fact that they do come down on people like a ton of bricks; or they come down on the LEO/SATCO who dares to stand up for their man by threatening to pull Examining Quals.
Interestingly (or not) I wonder what opinions are on the UK Airprox Board, you know that group of people that 'do not apportion blame'. Yet take a cursory look at any of the blue books and in the reports you'll see sentences like 'although the controller was not mandated to blah blah under a BS he has a duty of care' and 'some board members suggest that the airmanship displayed by the pilot was .....'
We've got no chance of a truly just culture until everyone is on board and singing from the same hymn sheet. Just because Air Command and MAA say we have a 'just culture' doesn't mean one actually exists.
That said, it is getting better, slowly.
No amount of mouth music from Cmd changes the fact that they do come down on people like a ton of bricks; or they come down on the LEO/SATCO who dares to stand up for their man by threatening to pull Examining Quals.
Interestingly (or not) I wonder what opinions are on the UK Airprox Board, you know that group of people that 'do not apportion blame'. Yet take a cursory look at any of the blue books and in the reports you'll see sentences like 'although the controller was not mandated to blah blah under a BS he has a duty of care' and 'some board members suggest that the airmanship displayed by the pilot was .....'
We've got no chance of a truly just culture until everyone is on board and singing from the same hymn sheet. Just because Air Command and MAA say we have a 'just culture' doesn't mean one actually exists.
That said, it is getting better, slowly.
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Just culture can exist, but can sometimes only exist as long as the posting cycle in the command chain.
There are some real megalomaniacal very senior officers out there (star rank) who are hellbent on perception as opposed the right decision. Perception gets you promoted, doing the right thing doesn't.
How many senior officer shriv and pjhq table top exercises include command decisions based upon supervision, authorisation and flight safety? I don't know, but I bet all are designed around moulding commanders to be op focussed rather than make balanced risk decisions. At how many table tops have individuals turned around and said "we aren't launching for a low priority mission as I have supervisory concerns?"
What is going to get a senior officer promoted? Performing under a situation of complete lack of resource, pushing the limits, perhaps bleeding his guys dry, or someone who speaks out and says we don't have enough to complete the task?
If the RAF very very senior hierarchy is serious about just culture, they need to make a serious statement and carry out very public actions to demonstrate their devotion and understanding of just culture. Such as sacking anyone who blatantly goes out their way to put their career ahead of just culture. star rank included.
There is a lot of learned helplessness out there too. People are reporting, but things are still getting worse, with lots of paperwork being generated, deck chairs on the titanic being shuffled, but nothing changing. Documenting risks on a psrr will not stop an accident. Spending some of that 2 billion cost underspend on risk mitigation will do however.
But seeing as the solution is
More people (not talking about numbers on books I'm talking about trained and experienced personnel here coming up with the goods)
More downroute spares and tooling/role support
Better training
Regulation based upon common sense and best practice, not the exceptional op requirement which has resulted from decades of cuts. How many 'short term' changes to regulation to meet a particular short term requirement are still there? 130 hours in a month springs to mind.....
Which involves spending money, I think we know we had better get used to rearranging chairs on the titanic.
There are some real megalomaniacal very senior officers out there (star rank) who are hellbent on perception as opposed the right decision. Perception gets you promoted, doing the right thing doesn't.
How many senior officer shriv and pjhq table top exercises include command decisions based upon supervision, authorisation and flight safety? I don't know, but I bet all are designed around moulding commanders to be op focussed rather than make balanced risk decisions. At how many table tops have individuals turned around and said "we aren't launching for a low priority mission as I have supervisory concerns?"
What is going to get a senior officer promoted? Performing under a situation of complete lack of resource, pushing the limits, perhaps bleeding his guys dry, or someone who speaks out and says we don't have enough to complete the task?
If the RAF very very senior hierarchy is serious about just culture, they need to make a serious statement and carry out very public actions to demonstrate their devotion and understanding of just culture. Such as sacking anyone who blatantly goes out their way to put their career ahead of just culture. star rank included.
There is a lot of learned helplessness out there too. People are reporting, but things are still getting worse, with lots of paperwork being generated, deck chairs on the titanic being shuffled, but nothing changing. Documenting risks on a psrr will not stop an accident. Spending some of that 2 billion cost underspend on risk mitigation will do however.
But seeing as the solution is
More people (not talking about numbers on books I'm talking about trained and experienced personnel here coming up with the goods)
More downroute spares and tooling/role support
Better training
Regulation based upon common sense and best practice, not the exceptional op requirement which has resulted from decades of cuts. How many 'short term' changes to regulation to meet a particular short term requirement are still there? 130 hours in a month springs to mind.....
Which involves spending money, I think we know we had better get used to rearranging chairs on the titanic.
Last edited by VinRouge; 25th Oct 2013 at 10:28.
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Having experienced this 'Just Culture' from the wrong side I say no, we are not there yet.
Submitting reports cannot solve problems on their own, to create a culture we need fair and just treatment of individuals following unintentional acts and errors. Reputation and outside perceptions are rather large barriers at present and I would like to see a little more loyalty and backbone from our upper levels who sometimes value their own careers more highly than the success of the system.
Agreed, Sir. Actions speak louder than words.
Submitting reports cannot solve problems on their own, to create a culture we need fair and just treatment of individuals following unintentional acts and errors. Reputation and outside perceptions are rather large barriers at present and I would like to see a little more loyalty and backbone from our upper levels who sometimes value their own careers more highly than the success of the system.
Just because we say we have a Just Culture doesn't mean one actually exists
Given the huge changes in recent times with the DH construct it may be helpful to keep this thread for those still serving and perhaps those who have left in the last year or so. Those of us who still serve can still remember what it was like 25, 20, 15, 10 years ago if any comparisons are needed.
The purpose of introducing a "just culture" is not to promote change, but to cover the arses of the politicians when they make changes which will do the opposite of promoting justice, e.g. only approving the promotion of VSOs who say "Yes Sir, and that won't affect our capability Sir" to every proposed budget cut.
One look at every other branch of the Government will tell you that.
The only solution is to elect MPs who actually have moral, just values. Good luck with that - and that grass isn't any greener outside the UK.
One look at every other branch of the Government will tell you that.
The only solution is to elect MPs who actually have moral, just values. Good luck with that - and that grass isn't any greener outside the UK.
If the message or event is deeply uncomfortable for someone in the higher echelons then the retribution can be brutal, even if someone is expressing an airworthiness concern.
Spot On.
This site
https://sites.google.com/site/militaryairworthiness/
has published the evidence and named the DE&S secretariat at Abbey Wood who continues to brief against people who express airworthiness concerns. Will Wg Cdr Spry care to comment?
Do you still have that supposedly 'anonymous' form for submitting Flight Safety incidents that you have either committed or seen committed? The one where you had to put your name, rank and contact details on the bottom "just in case IFS [as was] staff needed to contact you to discuss your submission".
The gp capt at IFS was most put out when I suggested that the line "these contact details will only be used by IFS staff" should be added to those other standard phrases "The cheque is in the post", "Don't worry, MT will pick you up" and anything told to you by your desk officer
The gp capt at IFS was most put out when I suggested that the line "these contact details will only be used by IFS staff" should be added to those other standard phrases "The cheque is in the post", "Don't worry, MT will pick you up" and anything told to you by your desk officer
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I once told my Stn Cdr to his face during my ACR debrief that I didn't believe him when he told me the RAF had a "just culture" ( it was the mid 90s so not sure if the actual phrase "Just Culture" had been invented but that's what he was talking about), he took it rather well to be honest.
There had been a recent incident where someone had indeed been f*cked over by the system, including that Stn Cdr, and I merely pointed out that "the system" can talk the talk all it likes, but all that can be undone by a single poor decision, and that there was just such an undercurrent among the JO aircrew on his Stn. The actual incident was never mentioned, but he knew what I meant.
Still surprised I got away with being quite so blunt.
There had been a recent incident where someone had indeed been f*cked over by the system, including that Stn Cdr, and I merely pointed out that "the system" can talk the talk all it likes, but all that can be undone by a single poor decision, and that there was just such an undercurrent among the JO aircrew on his Stn. The actual incident was never mentioned, but he knew what I meant.
Still surprised I got away with being quite so blunt.
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A cynic would argue that the 'Just culture' policy is a buffer zone between Haddon Cave and the MoD to provide an Early Warning System to the corridors of power of impending Risk of litigation. Otherwise known as a*** covering smoke and mirrors.
However the difference in overall Flight Safety data between today and pre millennium is most impressive, so something is working.
However the difference in overall Flight Safety data between today and pre millennium is most impressive, so something is working.
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 together 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.
I hope things are better.
Last edited by MG; 25th Oct 2013 at 18:28. Reason: Spooling
I agree with several comments made here.
I think the system is really trying to encourage a Just Culture on the front-line (ie flying) but as has been said, it can all so easily be undone by one decision from a higher rank, possibly even a benign one but one that is not explained correctly or is mis-perceived by the wider audience.
Is the safety system better than it was 20 or 30 years ago? Undoubtedly. Is it being misused by individuals to cover a**e, I don't know. The cynic in me believes possibly, the FSO in me hopes no.
I have seen some very positive benefits at my Stn from the revision of RAF FS, and for me as a pilot, that's what I want.
I think the system is really trying to encourage a Just Culture on the front-line (ie flying) but as has been said, it can all so easily be undone by one decision from a higher rank, possibly even a benign one but one that is not explained correctly or is mis-perceived by the wider audience.
Is the safety system better than it was 20 or 30 years ago? Undoubtedly. Is it being misused by individuals to cover a**e, I don't know. The cynic in me believes possibly, the FSO in me hopes no.
I have seen some very positive benefits at my Stn from the revision of RAF FS, and for me as a pilot, that's what I want.
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This takes me back a few years now where we had an incident occur on the ground during servicing. The report went in (can never remember the actual name of it!), where our line management all the way up to SENGO was covering us and not apportioning blame.
When the incident was covered in the magazine, our OC Eng at the time, screwed us over, placing all blame on us rather than the system. This is after we had been promised top cover on the station. It definitely affected a lot of the lads on shift, as they didn't feel comfortable reporting on any issues because of the **** storm that rolled down onto us all.
When the incident was covered in the magazine, our OC Eng at the time, screwed us over, placing all blame on us rather than the system. This is after we had been promised top cover on the station. It definitely affected a lot of the lads on shift, as they didn't feel comfortable reporting on any issues because of the **** storm that rolled down onto us all.
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one rule for one one for another
I owned up to a mistake I made got thanked for my honesty 2 months later received a letter about my error threatening me with dismissal,incorrect procedure followed by higher management,on this day in question Jengo made some mistakes also I was told it does not matter he is posted.Don,t talk to me about a just culture until aircrew and higher management receive the same training as groundcrew, learn from mistakes and not cover them up.I have evidence of this but not going to discuss on open forum.
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One of the problems with the "Just Culture" as I have witnessed it, is the opposite of what many are posting here.
As a 33 year time served engineer I saw many occasions where a person had negligently worked outside of a laid down procedure or practice and received nothing more than a "don't do it again" or "write a Cockpit article".
The fear that they will "lawyer up" and potentially uncover unit managerial failings during the process often causes a "soft" approach.
I still believe that removing someone's supervisory status for "re-education" works wonders to focus the attention, or giving a lad monthly QM checks should happen to make him realise he needs to do better.
Troop the buggers once in a while, if the procedure is in the book and they willfully ignore it, they are breaking the rules and need to be told so.
Cheers
As a 33 year time served engineer I saw many occasions where a person had negligently worked outside of a laid down procedure or practice and received nothing more than a "don't do it again" or "write a Cockpit article".
The fear that they will "lawyer up" and potentially uncover unit managerial failings during the process often causes a "soft" approach.
I still believe that removing someone's supervisory status for "re-education" works wonders to focus the attention, or giving a lad monthly QM checks should happen to make him realise he needs to do better.
Troop the buggers once in a while, if the procedure is in the book and they willfully ignore it, they are breaking the rules and need to be told so.
Cheers