Just Culture; thread lost in ...
Thread Starter
Just Culture; thread lost in ...
An example from a non US, non EASA operator. A good statement, maybe, but has it been applied as intended.
"Non-punitive reporting of incidents, accidents and error is an essential element of our new Safety Management System,
It is therefore essential that all information affecting safety is freely available within xxx. All personnel can feel confident that they can disclose any such information without fear of retribution.
As such, I fully endorse non-punitive incident/accident and error reporting within xxx. This will develop and foster a culture of mutual trust, in which we adopt a team approach to resolve problems and prevent recurrences.
Of course, this does not imply that xxx will tolerate negligence or wilful violations of standard operating procedures, policies or regulations.
signed MD"
Also see:
http://www.skybrary.aero/bookshelf/books/233.pdf
see Annex C3
And background material: just Culture might not be as good as intended, or a solution for current safety issues.
Hindsight 18 - SKYbrary Aviation Safety see editorial papers
https://humanisticsystems.com/2014/0...ure-where-now/
Just Culture | Sidney Dekker
http://www.hospitalmanagementasia.co...0_en_file1.pdf
NLR-ATSI Is a just culture the just way to safety intelligence
"Non-punitive reporting of incidents, accidents and error is an essential element of our new Safety Management System,
It is therefore essential that all information affecting safety is freely available within xxx. All personnel can feel confident that they can disclose any such information without fear of retribution.
As such, I fully endorse non-punitive incident/accident and error reporting within xxx. This will develop and foster a culture of mutual trust, in which we adopt a team approach to resolve problems and prevent recurrences.
Of course, this does not imply that xxx will tolerate negligence or wilful violations of standard operating procedures, policies or regulations.
signed MD"
Also see:
http://www.skybrary.aero/bookshelf/books/233.pdf
see Annex C3
And background material: just Culture might not be as good as intended, or a solution for current safety issues.
Hindsight 18 - SKYbrary Aviation Safety see editorial papers
https://humanisticsystems.com/2014/0...ure-where-now/
Just Culture | Sidney Dekker
http://www.hospitalmanagementasia.co...0_en_file1.pdf
NLR-ATSI Is a just culture the just way to safety intelligence
Thread Starter
LFAJ, re the 'question/ problem'. This was in reply to a 'lost' thread which requested an example of a Just Culture statement.
From a distant viewpoint, meeting the regulatory requirement for a JC appears more hoop jumping than providing practical value; i.e. An operator has a documented process and accountability, but evidence of meaningful application re safety improvement is hard to find.
Does a JC really help safety. 'Honest' mistakes may be reported, but are the underlying reasons / contributing factors fully investigated and shared. And do routine operational errors really represent the precursors to the extreme, 'unforeseeable' accidents.
From a distant viewpoint, meeting the regulatory requirement for a JC appears more hoop jumping than providing practical value; i.e. An operator has a documented process and accountability, but evidence of meaningful application re safety improvement is hard to find.
Does a JC really help safety. 'Honest' mistakes may be reported, but are the underlying reasons / contributing factors fully investigated and shared. And do routine operational errors really represent the precursors to the extreme, 'unforeseeable' accidents.
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A Just Culture depends on who decides as to whether or not a certain action was negligence, a wilful violation or a straight forward mistake. Such a call should only really be made by your peer group because only they can see things as you do. Management have a dog in the fight, so to speak, HR are typically a waste of space and the trainers should be part of the solution. Even a panel of experts are not really up to the job as they are too far removed from the nitty-gritty and nuances of day-to-day operations. And for Christ's sake, make sure nobody uses Reason's flow chart. It starts of with you being guilty, just like they used to do things in the Middle Ages before they drowned a witch. The starting point should be "Did this person come to work today to do a bad job?" If the answer is no, then you start finding out how they ended up doing so. And even if you found the victim lacking in some aspects of their performance, get them to help you fix the system so others don't repeat this person's past.
Last edited by Piltdown Man; 11th Nov 2016 at 08:56. Reason: minor corrections
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Pretty good explanation by the CAA available on the YouTube.
https://www.youtube.com/watch?v=ugl9FaBOlKA
https://www.youtube.com/watch?v=ugl9FaBOlKA
And how might the CAA video fit in with the actual reporting culture?
http://publicapps.caa.co.uk/docs/33/...%20Culture.pdf
http://publicapps.caa.co.uk/docs/33/...%20Culture.pdf