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

2. 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!

3. 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

4. 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?

5. 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

6. 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!

7. 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

8. 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

9. 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!

10. 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

11. 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!

12. 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

13. 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!

14. 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: