Just Culture George Monteiro Principal Airworthiness Surveyor

Just Culture in Aviation Safety: Key Topics What is a just culture? Impact of organisational culture on safety performance Just, reporting, informed and learning cultures Legislation, guidance and policies building trust Assessing and measuring: determining culpability Just Culture and safety improvement Key topics as listed within course description (as advertised) – Each key topic become a module of the course. What is a Just Culture? The impact of organisational culture on safety performance Just, reporting, informed and learning cultures as part of a developing safety culture – what does that mean to me? Legislation, guidance and policies building trust Assessing and measuring Just Culture: determining culpability Just Culture and safety improvement Its about the application of just culture rather than the term itself

Just Culture in Aviation Safety: Key Topics What is a just culture? Impact of organisational culture on safety performance Just, reporting, informed and learning cultures Legislation, guidance and policies building trust Assessing and measuring: determining culpability Just Culture and safety improvement Key topics as listed within course description (as advertised) – Each key topic become a module of the course. What is a Just Culture? The impact of organisational culture on safety performance Just, reporting, informed and learning cultures as part of a developing safety culture – what does that mean to me? Legislation, guidance and policies building trust Assessing and measuring Just Culture: determining culpability Just Culture and safety improvement Its about the application of just culture rather than the term itself

Not entirely a new idea Hurricane production 1940 Just Culture Not entirely a new idea A fault revealed voluntarily will be treated leniently but a fault concealed may lead to serious consequences for the workman, not to mention the pilot Value to the people we oversee Hurricane production 1940

How people feel – Psychological What is a Just Culture? Safety Culture – Just Culture – Learning Culture? Just Culture Safety Culture Learning Culture In a just culture errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action A learning culture means that an organisation is able to learn from its mistakes and make changes.  It will also ensure that people understand the SMS processes at a personal level Safety Culture Slide animated - points in order of animation: Safety Culture Not physics or math It is a touchy feely subject. Don’t be to precise on definitions – wasted effort Learning Culture Trying to get people behind the SMS is fundamental for SMS Just Culture Changes the no blame culture into the Just Culture. Allows people to admit “I screwed up” Try and divorce the culture of the company to actually what happened. How people feel – Psychological

Just Culture: Reasons to Report, or not….. YES – Report it! Don’t want aircraft to crash I know I’m supposed to Somebody saw me It might happen again I might get thanked The system will support me It’s the law Easy to complete a report NO – Hide it! I might get fired Nothing will change I’ll look foolish I might lose my Licence Nobody noticed It’s unimportant It’s too difficult If you are not sure report it. Not easy to complete a report. It is his job / responsibility It’s what he’s paid to do. Discuss each point, one at a time. (Each bullet animated one at a time) Easy to complete - on the other hand they may not be if the system you use is not easy. It is maybe worth considering that for some cultures reinforcing that its your duty to report it will help ie Japanese Culture Its about creating the environment where they can and will report issues

What is a Just Culture? - Reminder Making use of the data Cultivating an atmosphere where people have confidence to report safety concerns without fear of blame. Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting. Informed Learning Flexible Just Reporting Organisation collects and analyses relevant data, and actively disseminates safety information. Learning from the mistakes Safety Culture Slide is animated Dr James Reason has suggested that safety culture consists of five elements: An informed culture A reporting culture A learning culture A just culture A flexible culture Animated, in order: In a just culture errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action. A reporting culture means cultivating an atmosphere where people have confidence to report safety concerns without fear of blame.  Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting.  In an informed culture the organization collects and analyses relevant data, and actively disseminates safety information.   A learning culture means that an organization is able to learn from its mistakes and make changes.  It will also ensure that people understand the SMS processes at a personal level.  A flexible culture is one where the organization and the people in it are capable of adapting effectively to changing demands. Each one is relevant and do build on each other. The type of reports that have gone through the system will show you how mature it is. Organisation is able to learn from its mistakes and make changes.  It will also ensure that people understand the SMS processes at a personal level. Errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action. Organisation and the people in it are capable of adapting effectively to changing demands.

Just Culture Definition Legislation, Guidance & Policies Building Trust: Legislation & Guidance Guidance material CAP382 The Mandatory Occurrence Reporting Scheme further amplifies this protection of the reporter A Statement by the CAA Chief Executive describes: Assurance regarding prosecution Confidentiality of reports Possible action by employers Action in respect of licences Just culture Just Culture Definition Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated Definition originally came from 996 Air Traffic Regulations. Just Culture definition will also appear in the new EASA regulations. If you want to use a definition in your policy then this could be the one you use. Deciding whether gross negligence was involved is not always straightforward. This will be discussed. Making sure you have the procedures in place before something happens and you need to use them. The challenge is how to interpret and apply the definition www.caa.co.uk/cap382

Assessing & Measuring: James Reason – Culpability Model Substitution Test – refer to next slide for further details Question to peers: “Given the circumstances, is it possible that you could have made the same or a similar error” If answer “yes” then blame inappropriate. The best people can make the worst mistakes. See Handout (Slide) James Reason (Swiss cheese) Academic Very general and can be used in any situation NOT just aviation.

Assessing & Measuring: Patrick Hudson – Just Culture Model THE ORGANISATION See Handout Another academic one. Work across the top and then you can work your way down. This is a few years back and has since moved on. The line in the sand (that is when you think about firing someone)

Assessing & Measuring: FAiR2TM System – Flowchart Analysis of Investigation Results See Handout – 2 pages copy of slides (next slide does have the second part of the tool) Instructor note: Baines Simmons maybe verbally mentioned – objective comments only (please do not provide any subjective view points) The blue shaded boxes relate to the next slide Tools Summary - If there is one right way it would be in the regulation. Up to the individual organisation to decide what works for them. FAiR Version 2.0 - March 2015 © 2015 Baines Simmons Limited

Just Culture & Safety Improvement: Maintaining Focus Wrong Screws Window Blow-out Contributing Factor Contributing Factor ERROR EVENT Fred makes an error by using short screws which results in a window blow-out event. – Fred’s error, incompetent? Get rid of Fred, fixed! Fred doesn’t work in a vacuum, he is surrounded by contributing factors and it is these we need to focus on. Our process should enable us to remove the emotion from the scenario to allow organisational learning and improvement. If it hadn’t been Fred could it still have happened? If so the organisation needs to address the contributing factors, not sack Fred! Contributing Factor Contributing Factor

Just Culture & Safety Improvement: Effects of an ‘Unjust Culture’ Employees unlikely to report Information source dries-up Unsafe practices driven underground Reputational damage – whistleblowing Regulatory compliance failure Unaware of organisation’s risks – no mitigation Serious Incident or Accident? Lets think of the flipside of not having a Just Culture. Managers – Corporate manslaughter.

Why has Just Culture become so Important? Safety Promotion Safety Policy & Objectives Safety Risk Management Safety Assurance Safety Culture Remember this? The SMS Helicopter Informed Learning Flexible Just Reporting Safety Culture

Understanding of SMS: Practically, What is a SMS? What do we not want to happen? How do we prevent it happening? Take appropriate action How do we check it worked? Managing your risks to prevent the ‘bad’ things happening Accepting that things will go wrong but minimise the consequences A means to identify and understand your safety risks Slide animated. Managing your risks to prevent bad things happening Accepting that things will go wrong but minimise the consequences A means to identify and understand your safety risks (know your unknowns) (click to animate these bullets) It is more than a safety manual It is more than a database It is more than a quality management system It needs the right safety culture

Questions????