Job Brüggen CANSO Safety manager ATC The Netherlands Just Culture Job Brüggen CANSO Safety manager ATC The Netherlands

Source: Commercial aviation accidents, 1958 – 2014, A statistical analysis, Airbus

Leadership Safety Management Safety Culture Just Culture Inspire from the top Safety Management Actively managing risks Safety Culture The enabler Just Culture Rock bottom

Why do we need a Just Culture? Where FEAR is leading, people will not learn to improve, but people will learn not to get caught. They want to appear good, in stead of be good. Learning is safer than punishing!

Publish your JC Policy Based on what is internationally recognised as good practice: The objective of having the JC policy people are coming to work to give their best effort. people to perform optimally without fear for unjust punishments. is encouraging exemplary behaviour support and protect individuals in their safety tasks Will be accompanied by practical procedures Highest organisational level will actively support this JC Policy Endorsed and committed to by the workforce

JC Procedures: protection Protection of safety data Safety data, information and records should be protected against access by non-authorised personnel. de-identification of safety reports, setting access levels, Protection of reporter Protecting the reporter is of paramount importance. Names of reporters will never be released. Reports are de-identified. In case the reporter finds himself charged (on the basis of the report) the organisation will support the reporter as far as reasonably practical.

JC Procedures: who draws the line? A process is described how human behaviour is being interpreted. The basic structure for judging people's actions is the normal task of the line management, reporting up to the chief executive.

JC Who draws the line (2) A process how the organisation addresses human performance variability. agree with the workforce what is normal professional behaviour and what is not. how to interpret human behaviour, whilst protecting the norms and values of incident investigation. This could take the form of a committee that advises about human behaviour. Find out what mechanism works best for the company and the workforce. tools to assist with the interpretation.

JC Procedures: Tools A methodology is available for interpreting human behaviour Several classification schemes (free or commercial) that could be used for this. Alternatively, an organisation may develop their own scheme. A classification scheme to help in the interpretation of human behavioiur. Examples David Marx Baines & Simmons www.safetyandjustice.eu Hearts and Minds

JC Procedures: Tools (2) A flow chart to help in determining a class of human behaviour. Assisting the interpreter in selecting the right class of human behavior Ensure that no crucial steps are forgotten, like the routine test (does this happen often?) or the substitution test (could somebody else have made the same error, or: Is everyone doing the same thing?)

Promotion Communications about the existence / application of a Just Culture in the organisation. Special training programmes to instruct / teach people how to install / maintain a good Just Culture in the organisation. About JC ‘events’ Legal support Lead by example

Benchmarking with other industries If possible, current practice may be compared with likewise organisations or industries and useful / good practice can be incorporated in the organisation. Vice versa, good practice can be shared with other industries or similar organisations.

References Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon Hearts and Minds available at the Energy Institute GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment.  Baines & Simmons. FAiR® System (Flowchart Analysis of Investigation Results) Reason. Managing Risks of Organizational Accidents.Amazon. Reason. Human error: models and management.  Hudson. A new model for a Just and Fair Culture. Hudson. Safety Culture – Theory and Practice Eurocontrol Skybrary - Link to Just Culture material Eurocontrol. Establishment of Just Culture principles in ATM safety data reporting and assessment. Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for Accidents David Marx. Whack a mole. The price we pay for expecting perfection. Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial System European Commission: EU REG 374/2014 ICAO Safety Of Information Protection TaskForce Eurocontrol Just Culture Policy www.safetyandjustice.eu