Presentation by Integra Consult ”Just Culture” Where does it start? Where does it end? Presentation by Integra Consult Denmark

Training is a key issue in a ”Just Culture” One of the biggest ATM challenges today: Air Traffic Control is based on ”old” work culture The strive for better Safety performance is often technology driven Safety Culture enhancements is far from exploited enough There is a need for change in human behaviour, too!

Why ATC is still ”old fashioned”? ATC is a ”closed society” ATC is a high prestige job Knowledge transfer is done by ”father to child methods” (…I show you how to do it) Once Controller is forever Controller Mobility among ATCOs is limited New ideas are – generally – not welcomed In the name of Safety even justified changes can be rejected by ATCOs Safety improvements are often technology centered

How can we build on these Qualities? Why ATC is so Safe? ATCOs very much like their job Selection and Training is very demanding Routine is an important part of the job Teamwork is well developed How can we build on these Qualities?

How can we solve this contradiction?! Traditionally minded people who reject changes .. but at the same time enthusiastic specialists who do a great job! Training! Culture change

The relationship between ESARR2, ESARR5 and Safety Culture To develop Cultures that increase Safety, we have to Bring Safety “learning” into training (ESARR5) … … and we have to know where the weaknesses are (ESARR2)! Valuable information to be used in training can be collected from the analysis of the Incident Reports!

Lessons learnt from the Danish Safety Occurrence Reporting System What happens when a Safety Culture is missing?: The Operational ”norm” is locally defined Safety margin Infringements can become a ”normal” method of operation ”Online” discussion of Safety (standards) do not exist The negative drift in Safety becomes hard to detect before the ”big bang” A Safety Culture must be actively maintained

Lessons learnt from the Danish Safety Occurrence Reporting System Teaching Safety Culture Include Safety Culture in all training activities Ab initio Recurrent Controller Training Competency Assessment A Safety Culture must be actively maintained

Lessons learnt from the Danish Safety Occurrence Reporting System Teaching Safety Culture to; OJTI instructors, Competency Assesors And any other ”strong” Culture bearers Will create a new level of Safety Ambassadors and a ”re-created” ownership to Safety in your ATM operation!

Lessons learnt from the Danish Safety occurrence Reporting System Maintaining a Safety Culture Create a possibility for the Controllers to contribute to Safety; A Reporting System Find good learning points from the incoming Reports, Analysis and Investigation Use the learning via available methods; Ab initio training Recurrent training Competency Assessment

Results from the Safety Culture change after 5 years, Danish ANSP Lessons learnt from the Danish Safety Occurrence Reporting System Results from the Safety Culture change after 5 years, Danish ANSP Highest number of A/C Operations ever Lowest number of Separation losses!

ESARR5 adoptation by AZANS Restructure current training modules Full compliance with ESARR5 Promote “Train the Trainers” concept Combine in-house training with training abroad Propose the required changes for training/licensing regulation

Recommendations Culture change in ATM should comprise all phases of training! Creation of a ”core team” of best possible instructors should be a key issue! Involve ”fresh blood” inputs into your training mechanism! Many small Culture improvements will result in visible ATC ”system” improvement!

Contact: pmn@integra.dk Conclusion “An investment in and focus on Safety Culture could easily provide the same Safety improvement as a large Technical upgrade project!” Contact: pmn@integra.dk