JUST CULTURE Antonio Travaglione Safety Management Precondition ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Safety Management Precondition JUST CULTURE Antonio Travaglione IFATCA Aerodrome Safety Representative

Key element: Information ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Key element: Information Concept of Safe Culture “Just Culture” vs “No Blame Culture” The Public Interest

Safety Management Systems ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 INFORMATION Key element of Safety Management Systems Without information reporting, collection and sharing…

Safety Management Systems ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 INFORMATION IFATCA fully supports Safety Management Systems & promote reporting systems based on confidential reporting in a just culture

Reporting Systems INFORMATION IFATCA do not encourage ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 INFORMATION IFATCA do not encourage Reporting Systems unless there is “protection” for personnel providing the information, from misuse by the employer the public prosecutor

SAFE CULTURE Reporting culture Informed culture Just culture ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 SAFE CULTURE Prof. James Reason Reporting culture Informed culture Just culture

SAFE CULTURE Informed culture ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 SAFE CULTURE Prof. James Reason … is one that knows where the ‘edge’ is without having to fall over it first … is preoccupied with the possibility of failure and works continuously to become more resilient to its operational hazards Informed culture

SAFE CULTURE Reporting culture ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 SAFE CULTURE Prof. James Reason Reporting culture An informed culture depends on PEOPLE reporting near misses, errors and incidents, PEOPLE owning a “reporting culture”

SAFE CULTURE Just culture ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 SAFE CULTURE Prof. James Reason But people won’t report if they don’t trust the system, they certainly won’t report if they are disciplined or, worse, prosecuted, because of what they report. Thence, a reporting culture can only grow from a “just culture”. Just culture

11th ICAO Air Navigation Conference ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 11th ICAO Air Navigation Conference Under agenda item 2.1 “Safety Management Systems and Programs”, IFATCA presented Working Paper 92 titled “The need for a just culture in aviation safety management” Just culture All recommendations of this paper were accepted by the Conference

11th ICAO Air Navigation Conference ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 11th ICAO Air Navigation Conference Just culture “A culture in which front line operators are not punished for actions or decisions that are commensurate with their experience and training, but also a culture in which violations and wilful destructive acts by front line operators or others are not tolerated”

11th ICAO Air Navigation Conference ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 11th ICAO Air Navigation Conference Just culture Judicial aspects must be adequately addressed in ICAO guidance material on Safety Management Systems for ATS.

11th ICAO Air Navigation Conference ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 11th ICAO Air Navigation Conference review existing aviation laws with the aim to remove factors that could be deterrents to the collection and analysis of valuable safety-related information; Just culture develop legislation that adequately protects all persons involved in the reporting, collection and/or analysis of safety-related information in aviation

Just Culture Honest Mistakes Zero tolerance Blame Free Gross ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Just Culture Honest Mistakes Gross negligence Gross negligence Criminal offences Omissions Slips Lapses Mistakes Violations Slips Lapses Criminal offences Omissions Mistakes Violations Errors: 1) unintentional deviations from planned and desired actions: - slips (memory errors) - lapses (attentional errors); 2) deficiencies or failures in the judgemental and/or inferential processes which may generate an incorrect goal or may lead to the failure of the selected goal (mistakes). Violations: deliberate, but not necessarily reprehensible, deviations from those practices deemed necessary (by engineers, managers and regulatory agencies) to maintain the safe operation of potentially hazardous system (Reason, 1990). From these definitions it results that while slips, lapses and mistakes can be associated with individual cognitive processes and may be affected by individual internal aspects, such as personality and attitudes, that are always difficult to formalise, violations must be identified in relation to a socio-technical context which affects procedures, behavioural attitudes, practises, etc. Deliberate Unintentional Zero tolerance Blame Free

ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 The Public Interest Legal regimes should be set up with the aim of protecting the public interest. In relation to transport, we assume that the public interest be to travel maintaining the system at its safest level

ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 The ANSPs Interest Offer the best and safest service to their customer… And to earn money from that (if private)

L The Danish example - Mutual Trust ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 The Danish example - Mutual Trust Aeronautical Organisations (Regulator, ANSP, ATCOs Association) Law Makers L Public Prosecutor

SAFETY MANAGEMENT Reporting culture Informed culture Just culture ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 SAFETY MANAGEMENT Reporting culture Informed culture Just culture

ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 CONCLUSIONS The legal world still holds the view that the system is inherently safe and that the humans are the main threat to that safety ... while the aviation industry recognises the central role of humans in making the system work safely, although they are subject to be involved in occurrences.

CONCLUSIONS We fully support ICAO efforts in this direction ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 CONCLUSIONS IFATCA supports the establishment of safety management systems (SMS) and promote the creation of reporting systems. These must be based on just culture in both the legal regime and the aviation industry. We fully support ICAO efforts in this direction

Antonio Travaglione atravaglione@enav.it ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Antonio Travaglione IFATCA Aerodrome Safety Representative atravaglione@enav.it