1. 1  Copyright 2005 EUROCONTROL Legal Impediments to Just Culture

2.  Copyright 2004 EUROCONTROL 2 Content n Performance review and safety; n Safety survey into the “just culture”; n Issues identified by the survey: –Legislation; –Regulation; –SMS; –Local culture; n Follow-up; n Conclusions.

3.  Copyright 2004 EUROCONTROL 3 Performance Review n 12 independent senior experts; n Very wide aviation expertise; n Appointed for two years, renewable once; n Running a strong, transparent and independent performance review system; n Ten-strong supporting unit.

4.  Copyright 2004 EUROCONTROL 4 Time Safety Delay Cost Effectiveness Access Reliability Predictability Environment Flight Efficiency Flexibility Equity Other New KPAs Key Performance Areas

5.  Copyright 2004 EUROCONTROL 5 Incident reporting n Just culture needed. n European safety performance unknown Why? n Lack of consistent data Why? n No reporting Why? n Fear of consequences So?

6.  Copyright 2004 EUROCONTROL 6 What is “Just Culture”? n See IFATCA definition criminal acts gross negligence Inadequate attitude Monitored by management Disciplinary actions as required Competence of justice Addressed by SMS Single purpose: safety improvement Slips, lapses, etc. Honest mistakes Repetitive errors Deliberate acts

7.  Copyright 2004 EUROCONTROL 7 PRU/PRC Survey n Announced in 2001; n Supported by the SRU and EUROCONTROL Agency; n Started in October 2001. n Two phases: –Questionnaire sent to 28 States; –Interviews in 10 States plus Maastricht UAC; n Final report approved by the PRC; n Published in December 2002; n Sent to Provisional Council, States, Agency. n New survey in 2005, your assistance is required.

8.  Copyright 2004 EUROCONTROL 8 Right to know vs. safety n Safety performance is of public interest n Public has the right to know n Fine balance between those two: –Good safety requires measured safety, –Measured safety requires safety data –Safety data require safety reports, –Safety reports require ATCO confidence, –ATCO confidence require “just culture”. n The “just culture” has two main components: –Protection against public disclosure, –Protection against punitive measures.

9.  Copyright 2004 EUROCONTROL 9 EUROCONTROL Survey - Key Figures 61% 35% 4% YesNoNot answered ICAO Annex 13, section 5.12 implemented in national law

10.  Copyright 2004 EUROCONTROL 10 Main issues (1) n Significant legal/regulatory constraints to non- punitive reporting in many States. n As a result, many staff feel inhibited to report. n “Freedom of Information“ legislation is particularly difficult to deal with. Legislation

11.  Copyright 2004 EUROCONTROL 11 26% 63% 11% YesNoNot answered EUROCONTROL Survey - Key Figures Partial or total immunity from prosecution

12.  Copyright 2004 EUROCONTROL 12 49% 38% 13% YesNoNot answered Disclosure of a reporter's name EUROCONTROL Survey - Key Figures

13.  Copyright 2004 EUROCONTROL 13 n Safety regulation still not well developed; n Proper staff, legal tools and resources needed; n A strong, independent regulator is a guarantee for all. Main issues (2) Regulation

14.  Copyright 2004 EUROCONTROL 14 65% 35% NoYes Adequacy of safety reporting regulations EUROCONTROL Survey - Key Figures

15.  Copyright 2004 EUROCONTROL 15 Main issues (3) n Poor communication between various levels of management, as well as between management and ATCOs. n Safety management not always taken seriously. Safety Management

16.  Copyright 2004 EUROCONTROL 16 Existence of internal procedures EUROCONTROL Survey - Key Figures

17.  Copyright 2004 EUROCONTROL 17 Conclusions n Safety: part of the performance review n International agreements not always fulfilled; n Unfavourable legislation and/or regulations; n Wide awareness about the need of a just culture; n Vast education campaign needed for implementation; n The just culture elements identified locally; n Incident reporting must be encouraged.

18.  Copyright 2004 EUROCONTROL 18 EUROCONTROL Survey - Key Figures 16% 62% 3% 19% Yes NoNot answered No, but on going Existence of “just culture”

19. 19  Copyright 2005 EUROCONTROL ? Questions? Thank you!