1. The Just Culture Initiative
Roderick D. van Dam
Head of Legal Service, EUROCONTROL
ICAO / ASPA Regional Seminar
10-11 April 2007
European Organisation for the Safety of Air Navigation

2. Outline
Setting the (European) scene
Concept of Just Culture
Challenges
Way forward – European and International approaches

3. 24 Hours of Europe Air Traffic: September 10, 2004

4. Membership of the EU, EUROCONTROL and ECACIS FI
Eurocontrol (37 + European Community)
ECAC (42)
EU (27) RU NO SE EE XX LV DK LT KZ IE BY GB NL PL BE DE UA LU CZ SK MD AT FR CH HU RO GE SI AZ HR AM BA SR BG IR IT CG PT ES MK TR AL GR IQ SY CY DZ MA TN MT

5. EUROCONTROL European Organisation for the Safety of Air Navigation
EUROCONTROL Convention
13 December 1960
Amended Convention
Protocol 12 February 1981
Revised Convention
Protocol of 27 June 1997
Not yet in force – however, early implementation of certain provisions of the revised Convention

6. EUROCONTROL - CORE BUSINESS
Management of pan-European programmes
Research & Development work aimed at increasing Air Traffic Control capacity and safety in Europe
Operation of a Central Flow Management Unit
Collection of Route Charges on behalf of Member States and through bilateral agreements with non-Member States
Provision of training, education and knowledge transfer in Air Navigation Services inside and outside Europe
Provision of Air Traffic Services
Management of an international (4 States) ATC Centre: Maastricht
Development of an international (8 States) ATC Centre: CEATS

7. Setting the scene Accidents in 2001 & 2002 SAFREP
Strengthen the need for continuous safety improvements
Led to, inter alia, creation of Safety Data Reporting and Data Flow Task Force (SAFREP)
SAFREP
Report on ATM incident reporting culture: Impediments and Practices
Involving EUROCONTROL, European Commission, IFATCA, IATA, States and ANSPs representatives
Conclusions and Recommendations
EUROCONTROL to continue to actively support and cooperate with ICAO

8. Setting the scene European Safety Programme for ATM (ESP)
Supporting 42 ECAC States
Safety maturity to a minimum common level by December 2008
High Priority Area: Incident Reporting and Data Sharing
Special emphasis on “Just Culture”

9. ATM Safety Maturity in Europe50 55 60 65 70 75 80
2002
2003
2004
2005
2006
ANSPs
Regulator
Today Air Traffic Management in Europe is mostly cruising along nicely, which is a remarkable achievement.
Europe's ATM system is safe: Europe has not had a single ATM-induced fatal accident since 2002.
Moreover, the safety of both ANSPs and national Regulators is rising steadily.
According to a range of indicators measured by EUROCONTROL, in the last four years the safety maturity of ANSPs rose by 27 %, and that of regulators by 25 %.

10. Concept of Just Culture
What is “Just Culture”?
EUROCONTROL / SAFREP definition:
“A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated”
Definition to be submitted to
next ICAO Assembly

11. Concept of Just Culture
Main elements:
Actions, omissions and decisions expected from
someone with your level of training and experience
Not punished
Gross negligence, willful violations and destructive acts
Not tolerated

12. Concept of Just Culture
Objectives:
To provide increase in reporting
Not to justify absence of reporting
Evolved from punitive-free reporting, blame free reporting
To achieve a balance between interests of
safety (and protection of safety information)
while allowing proper administration of justice

13. Concept of Just Culture
Involving a number of players:
States (Regulators, prosecutors, etc.)
ANSPs
“Reporters” (e.g. controllers)
International / regional organisations
A number of challenges must be addressed to establish “Just Culture”

14. Challenges
Powers of judicial authorities vs. Protection of safety information
Both addressed by ICAO Annex 13:
Section 4.2 : Non – Disclosure of records
Legal Guidance: (new) Annex E
Not purpose of protecting safety information to interfere with proper administration of justice
Protection of qualified safety information under conditions is part of a State’s responsibilities

15. Challenges
Powers of judicial authorities vs. Protection of safety information
Relevant Assembly Resolutions:
A31-10: “Urges Contracting States (…) to implement voluntary and non punitive reporting systems”
A33-17: “Instructs the Sec. Gen. to develop appropriate guidance material related to laws and regulations to protect certain accident and incident records”
A35-17: “Instructs the Council to develop appropriate legal guidance that will assists States (…) to protect information gathered from all relevant safety data collection and processing systems, while allowing for the proper administration of justice in the State”

16. Challenges European Level – same “conflict” EUROCONTROL
Directive 94/56/EC on the investigation of civil aviation accidents and incidents
Directive 2003/42/EC on occurrence reporting in civil aviation
EUROCONTROL
ESARR 2 and Guidance Material
Directives
currently
under review
States shall refrain from initiating proceedings
(except in case of gross negligence)
No prejudice from employer
Without prejudice to applicable rules:
- penal law
- related to access to information by judicial authorities

17. Challenges Cooperation betweenJustice and ATM/Safety experts
Public interest
Safeguards
Respect roles and responsibilities
Address grey areas
The last challenge is one which could to a certain extent also provides solution for the other identified challenges.
It seems that in order to create an environment where the notion of Just Culture becomes part of reporting, there is a need to increase the cooperation between ATM / Safety experts and those involved with the administration of Justice.
Both Safety and Justice interest are both working for the public interest – there should be therefore room for dialogue and cooperation.
This should be done respecting a number of safeguards – not trying to create a system where for example the function of a prosecutor would be replaced by those of a safety experts – and vice-versa. You have to respect the roles, responsibilities and expertise of each party.
One way to improve the situation would be address a number of grey areas –
e.g. definition of gross negligence, wilful misconducts, honest mistakes to ensure that Justice and Safety /ATM experts speak the same language.
Could also develop environment where, for example, prosecutors could use their power of discretion regarding the launching or not of legal proceedings.

18. Challenges Communication and trust Training Trust at all level (ANSPs)
Staff / Managers
Between Managers
Important role of management
Training
Reporting is an obligation – part of professional duty

19. Challenges Liability of ATC Lack of harmonization National frameworks
Criminal
liability
Administrative
sanctions
Civil
Liability
Disciplinary
sanctions

20. Challenges Trend in Europe: ATC and criminal proceedings
Relatively recent trend
Further to an accident:
Linate case
Überlingen case
Mt-St-Odile case
Further to an incident:
Delta case

21. Challenges Increase of criminal proceedings - Why? Impact on reporting
Basic principles have not changed
Increase awareness of safety matters
Not solely affecting aviation
Impact on reporting
“Vicious circle”
Calls for Just Culture
Less reporting
More incidents/
accidents
Increase in legal
proceedings

22. Way Forward
Potential Impact on ATM safety recognised:
Incidents report are essential to ATM safety
Need to ensure flow of information
Need to provide environment supporting reporting (and address “fear” of reporting)
Just Culture concept –supporting safety reporting in a culture that is “just” to all concerned

23. Way Forward To achieve this…
Review and implement applicable legislative framework, structures and procedures
National level
International level
However – focus not only on legal framework:
Dialogue Justice / Safety
Trust and Communication
Training

24. Way Forward Aim for balance
Respecting roles and responsibilities of each party
Seek collaborative approach of all concerned
Use best practices and experiences
and
Endorse and further develop Just Culture at international level
Next ICAO Assembly