Non Punitive Culture
Thread Starter
Join Date: Oct 2001
Location: uk
Posts: 10
Likes: 0
Received 0 Likes
on
0 Posts
Non Punitive Culture
Non Punitive Culture
I work for an East Europe based airline; their OM has a statement in it as follows:
XXX AIR SUPPORTS A NON-PUNITIVE WORKING CULTURE AND ENCOURAGES INDIVIDUAL CREW MEMBERS TO FORWARD DETAILS OF ANY SAFETY, SECURITY, BEHAVIOURAL (CRM) AND FLIGHT IRREGULARITIES TO FLIGHT OPERATIONS IN ORDER TO KEEP FLIGHT STANDARDS HIGH.
HOWEVER WILFUL AND DELIBERATE VIOLATION OF FLIGHT OPERATIONS ORGANIZATION POLICIES AND/OR PROCEDURES WILL BE INVESTIGATED BY AIR SAFETY BOARD. DISCIPLINARY ACTIONS WILL BE TAKEN AS APPROPRIATE.
Unfortunately the words ‘Non Punitive’ have seemed to have been miss translated into ‘Punitive’.
All the pilots know that if they report anything, they will be invited for a chat with the DFO and if they don’t and it gets picked up by flight data monitoring then the same chat will occur. This will normally result in the Captain being downgraded to F/O and the F/O dismissed.
The latest incident occurred a few weeks ago when an aircraft lost radio contact over the middle of Europe for 40mins. Yes a serious event but not an unusual one. Every flight you hear calls on 121.5, XXX contact ______ on XXX.
After a quick and short Safety Board enquiry both pilots had their contracts terminated.
Maybe it’s me, but I always thought that the idea of ‘Non Punitive’ was to look at these events and find out how the company could improve its training/operation to stop it happing again.
In the company statement it says “wilful and deliberate violation”. I sure the pilots involved did not wilfully or deliberately lose radio communication.
I would be interested to hear how your company deals with this sort of thing.
I work for an East Europe based airline; their OM has a statement in it as follows:
XXX AIR SUPPORTS A NON-PUNITIVE WORKING CULTURE AND ENCOURAGES INDIVIDUAL CREW MEMBERS TO FORWARD DETAILS OF ANY SAFETY, SECURITY, BEHAVIOURAL (CRM) AND FLIGHT IRREGULARITIES TO FLIGHT OPERATIONS IN ORDER TO KEEP FLIGHT STANDARDS HIGH.
HOWEVER WILFUL AND DELIBERATE VIOLATION OF FLIGHT OPERATIONS ORGANIZATION POLICIES AND/OR PROCEDURES WILL BE INVESTIGATED BY AIR SAFETY BOARD. DISCIPLINARY ACTIONS WILL BE TAKEN AS APPROPRIATE.
Unfortunately the words ‘Non Punitive’ have seemed to have been miss translated into ‘Punitive’.
All the pilots know that if they report anything, they will be invited for a chat with the DFO and if they don’t and it gets picked up by flight data monitoring then the same chat will occur. This will normally result in the Captain being downgraded to F/O and the F/O dismissed.
The latest incident occurred a few weeks ago when an aircraft lost radio contact over the middle of Europe for 40mins. Yes a serious event but not an unusual one. Every flight you hear calls on 121.5, XXX contact ______ on XXX.
After a quick and short Safety Board enquiry both pilots had their contracts terminated.
Maybe it’s me, but I always thought that the idea of ‘Non Punitive’ was to look at these events and find out how the company could improve its training/operation to stop it happing again.
In the company statement it says “wilful and deliberate violation”. I sure the pilots involved did not wilfully or deliberately lose radio communication.
I would be interested to hear how your company deals with this sort of thing.
Join Date: Oct 2009
Location: Cloud Nine
Posts: 12
Likes: 0
Received 0 Likes
on
0 Posts
Don't shoot the messenger. It doesn't only apply in aviation; it does in general. Things will be shoved under the carpet when people see their peers who report things get punished. The job of the flight safety department at your airline (or the court in some unfortunate cases) is to determine whether there was gross neglect or deliberate malbehaviour. That can be a really tough job (especially for a judge who doesn't know an awful lot about aviation). Your airline is an exception I think, because pilots generally fear the court more than they fear their own airline.
Regards
Capriati
Regards
Capriati
Join Date: Aug 2009
Location: Lisbon
Posts: 995
Likes: 0
Received 0 Likes
on
0 Posts
Just Culture
From the ICAO website :
"However, the current level of incident reporting and data sharing is judged to be
insufficient, and the limited application of a “Just Culture” that is conducive to the reporting and analysis
of aviation safety occurrences is a contributing factor. A “Just Culture” is one in which “frontline staff 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.”"However, the current level of incident reporting and data sharing is judged to be
insufficient, and the limited application of a “Just Culture” that is conducive to the reporting and analysis
of aviation safety occurrences is a contributing factor. A “Just Culture” is one in which “frontline staff 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
Join Date: Feb 2002
Location: uk
Posts: 302
Likes: 0
Received 0 Likes
on
0 Posts
Violations etc
Unfortunately, this is a difficult situation to defend.
Certainly, there will be an SOP in place in every airline specifying the need, for instance to monitor 121.5 and to continuously monitor radio frequencies selected. So the company can argue that a violation, rather than an error took place.
However it would appear that sometimes the company culture is further away from what ICAO/JAR expects of them than the crew are from what is expected of them.
There are cases of overcrewed airlines using punitative measures to weed out crew instead of having to pay them to go.
I hope these airlines get bitten in the a..e when the next hiring boom comes around.
In my company, we actually get a letter of thanks for reporting something daft we did!
Provided you have not done something downright illegal, or wilfully dangerous, you should be encouraged to let others learn from it.
This is not a utopian dream, this is a JAR requirement!
Certainly, there will be an SOP in place in every airline specifying the need, for instance to monitor 121.5 and to continuously monitor radio frequencies selected. So the company can argue that a violation, rather than an error took place.
However it would appear that sometimes the company culture is further away from what ICAO/JAR expects of them than the crew are from what is expected of them.
There are cases of overcrewed airlines using punitative measures to weed out crew instead of having to pay them to go.
I hope these airlines get bitten in the a..e when the next hiring boom comes around.
In my company, we actually get a letter of thanks for reporting something daft we did!
Provided you have not done something downright illegal, or wilfully dangerous, you should be encouraged to let others learn from it.
This is not a utopian dream, this is a JAR requirement!
Thread Starter
Join Date: Oct 2001
Location: uk
Posts: 10
Likes: 0
Received 0 Likes
on
0 Posts
A similar occurrence happened in the airline to a very (very) senior captain 6 month ago, which included two fighter aircraft formatting on them. The only result from this was he issued a memo reminding crew to monitor 121.5.
Another question; if fighters get scrambled who pays?
Does the airline get a big bill?
Another question; if fighters get scrambled who pays?
Does the airline get a big bill?
Join Date: Oct 2009
Location: Quahog
Posts: 151
Likes: 0
Received 0 Likes
on
0 Posts
Without going into the actual event I think cactus jack told you all you need to know, really. The key to the event is whether the crew acted to the best of their ability or were negligent. No company in this business can afford to let safety lapses go unactioned, but the action needs to be relevant to the root cause of the problem. There is no point disciplining a crew who were following actual or prevalent procedures - the procedures or culture need to be addressed. Equally there is no point rewriting procedures if they were clearly not followed.
It is important that companies do understand and apply the principles of a Just Culture. If they are seen to blame individuals in every case all that will happen is people will stop reporting near-misses for fear of blame, and opportunities to improve safety will be lost.
It is important that companies do understand and apply the principles of a Just Culture. If they are seen to blame individuals in every case all that will happen is people will stop reporting near-misses for fear of blame, and opportunities to improve safety will be lost.
There are no limits
Join Date: May 2002
Location: Shrewsbury, England.
Age: 67
Posts: 505
Received 0 Likes
on
0 Posts
A well-written non-punitive reporting policy should, at least, contain the following three elements.
a. No employee shall be disadvantaged due to a report being submitted.
b. Should investigation of a report reveal negligence or wilful violation of regulations, policy or procedures, employees may be disciplined in accordance with company policy.
c. proactive submission of reports will be considered in a favourable light in the event of disciplinary action being taken against that employee
Or words to that effect.
Too often pilots have hidden behind poorly written policy and companies have failed to comply with their own policy - go figure. Just shows that there is a lack of understanding of the intent of a non-punitive policy.
a. No employee shall be disadvantaged due to a report being submitted.
b. Should investigation of a report reveal negligence or wilful violation of regulations, policy or procedures, employees may be disciplined in accordance with company policy.
c. proactive submission of reports will be considered in a favourable light in the event of disciplinary action being taken against that employee
Or words to that effect.
Too often pilots have hidden behind poorly written policy and companies have failed to comply with their own policy - go figure. Just shows that there is a lack of understanding of the intent of a non-punitive policy.
A couple years ago I joined a company in Canada that was far ahead of their contemporaries in implemented paper SMS. Transport Canada is in the process of gutting oversight and replacing it with SMS so they were very happy with this company.
A couple months into my employment I busted a minimum step-down during an approach. Non radar controlled environment, no FOQA monitoring, so nobody knew about it but me and the F/O. I filed the SMS report stating what had happened and why I thought it had happened (mandated abbreviated briefings, laborious and interminatble SOP calls, and others).
The chief pilot told me that it is my responsibility to follow minimums and that any further reports like this would earn me a letter of reprimand in my file.
You can guess how many SMS reports I have filed since then.
This company just passed Transport Canada's toughest SMS audit with flying colours.
A couple months into my employment I busted a minimum step-down during an approach. Non radar controlled environment, no FOQA monitoring, so nobody knew about it but me and the F/O. I filed the SMS report stating what had happened and why I thought it had happened (mandated abbreviated briefings, laborious and interminatble SOP calls, and others).
The chief pilot told me that it is my responsibility to follow minimums and that any further reports like this would earn me a letter of reprimand in my file.
You can guess how many SMS reports I have filed since then.
This company just passed Transport Canada's toughest SMS audit with flying colours.
Join Date: May 2002
Location: dubai
Posts: 942
Likes: 0
Received 0 Likes
on
0 Posts
Very often, lost communication problems are caused by two things:
-Not monitoring 121.5
-Not writing down the new frequency before change over. (Doesn’t matter how modern your avionics fit is, this must be done)
I don’t know why it happened in this case, as the punitive culture has probably stifled the information.
Let us all learn from others mistakes.
-Not monitoring 121.5
-Not writing down the new frequency before change over. (Doesn’t matter how modern your avionics fit is, this must be done)
I don’t know why it happened in this case, as the punitive culture has probably stifled the information.
Let us all learn from others mistakes.
Last edited by doubleu-anker; 17th Dec 2009 at 03:20.
Aviator
Join Date: May 2001
Location: Norveg
Posts: 483
Likes: 0
Received 0 Likes
on
0 Posts
The problem with the vast majority of companies, who all claim to have a non punitive reporting system, is what What Limits says:
'the hell is "negligence" and "willful violation"?
Negligence is actually a legal term – not a Human Factors term at all. It encompasses such things as:
- Standard of practice
- Skillfulness
- Prudence
- Reasonable care
- Foreseability of harm
etcetera...
So – it is not a definition at all: It is a series judgement calls, and thus this term does not belong in any Operations Manual!
Somebody will have to make those judgement calls. These calls are, of course, all made after the fact, in a warm conference room with plenty of time, coffee and lawyers. The big Q is really NOT where does the "line" between acceptable and unacceptable performance go – the real Q is ”Who gets to say” where that line goes? Who do we give the power to draw that line? As long as employees are not able to influence this decision, and it is always (by default) the Chief Pilot or some other pencil pusher / brown noser who does it, a non-punitive system will never be truly non-punitive.
One can never know whether some guy higher up in the hierarchy suddenly decides that you were "negligent".
I always choose my words wisely when (or, rather, IF) I submit a report in our reporting system. I also sometimes choose not to submit any report at all, because I know who really gets to draw the lines in our company. Sad but true...
b. Should investigation of a report reveal negligence or wilful violation of regulations, policy or procedures, employees may be disciplined in accordance with company policy
Negligence is actually a legal term – not a Human Factors term at all. It encompasses such things as:
- Standard of practice
- Skillfulness
- Prudence
- Reasonable care
- Foreseability of harm
etcetera...
So – it is not a definition at all: It is a series judgement calls, and thus this term does not belong in any Operations Manual!
Somebody will have to make those judgement calls. These calls are, of course, all made after the fact, in a warm conference room with plenty of time, coffee and lawyers. The big Q is really NOT where does the "line" between acceptable and unacceptable performance go – the real Q is ”Who gets to say” where that line goes? Who do we give the power to draw that line? As long as employees are not able to influence this decision, and it is always (by default) the Chief Pilot or some other pencil pusher / brown noser who does it, a non-punitive system will never be truly non-punitive.
One can never know whether some guy higher up in the hierarchy suddenly decides that you were "negligent".
I always choose my words wisely when (or, rather, IF) I submit a report in our reporting system. I also sometimes choose not to submit any report at all, because I know who really gets to draw the lines in our company. Sad but true...
