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

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

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

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

5. Reporting Systems INFORMATION IFATCA do not encourage
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

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

7. SAFE CULTURE Informed culture
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

8. SAFE CULTURE Reporting culture
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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”

9. SAFE CULTURE Just culture
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

10. 11th ICAO Air Navigation Conference
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

11. 11th ICAO Air Navigation Conference
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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”

12. 11th ICAO Air Navigation Conference
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

13. 11th ICAO Air Navigation Conference
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

14. Just Culture Honest Mistakes Zero tolerance Blame Free Gross
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

15. ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

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

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

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

19. ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

20. CONCLUSIONS We fully support ICAO efforts in this direction
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

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