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Swiss ATCA Just Culture Manual

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Category: Human Error
in Aviation
and Legal Process
Human Error in Aviation and Legal Process
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Safety is a continually evolving process of finding what makes organizations in high-consequence industries resilient, understanding their margin of safety and what puts them at risk. The concept of just culture supports organizational safety resilience by promoting an environment of openness that encourages reporting and learning from mistakes, free from fear of reprisal. Just culture emerged from the study of organizational culture influences on sociotechnical systems safety[1].

In High consequence industries, employees in safety sensitive positions work in vastly complex sociotechnical systems. Public debate about accountability and responsibility of individual actors spark when “near misses” or incidents are being investigated either by the accident and incident investigation bodies or the judiciary.

A ‘just culture’ aims to respond to anxiety about blame-free approaches on the one hand and a concern about people’s willingness to keep reporting safety-related issues on the other[2]. With the EC Implementation Regulation 376/2014 IFATCA has identified that Just Culture can be two faceted. One being at the corporate level and the other one at the judicial level. A just culture sets out the conditions that legitimize managerial (or judicial) intervention[3] in the sanction or restoration of individuals in the organization.

International (ICAO) and in particular the European Regulation on prevention of aviation accidents (996/2010) and the Regulation reporting of incidents (376/2014) explicitly allude to the delicate balance between the interest of justice (law) and safety.

Therefore, safety needs a prospective, forward-looking accountability and safety information becomes important to make the adequate changes. It is crucial to have safety-related events and issues reported, to understand – in oversimplified words – the difference between ‘work as done’ and ‘work as imagined’ which is shaped by ‘work as prescribed’ in rules and procedures, to listen to multiple narratives from all the stakeholders involved and to share the experience and the ensuing information in order to let the system evolve into a safer one for all those following us in the system.

This can only be achieved when individuals – no matter whether they are managers, project owners, engineers, ATSEP, ANSE or ATCO – are able, allowed and willing to share safety information by reporting incidents and other safety-related issues, and when there is a commitment to act on what is shared in order to learn and make things better.

Today’s challenge is that the reporter will only share this information if s/he can do this in an honest, non-discriminatory and non-punitive nature.

That is where Just Culture comes in. Just Culture is “a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated“ [European Commission, Eurocontrol & IFATCA]. It is one means to achieve a better working environment by holding people accountable – allow people to give and share their account – without punishing them, and consequentially allowing the system to learn from past events.

Just Culture has found its way into many safety-critical business branches – such as transport, medicine, nuclear technology and more – and recent regulation acknowledges the need for protecting the reporter. However, that protection is not (yet) reflected in national legislation, nor has the administration of justice been given any guidelines regarding its important role in a “Just Culture”, which is both accepted by the current regulation. Motivated by the numerous prosecutions, court cases and fines the Swiss administration of justice has started or issued on incidents in Air Traffic Management (ATM), Swiss ATCA produced the attached guidance material for its members and other involved operators and personnel (ATCOs, ATSEP and management). This version is an adapted version of the original which has been distributed internally in November 2017. Swiss ATCA hopes it is a contribution to the discussion on the delicate balance between the administration of justice and the safety world. Though embedded in the Swiss legal and operational processes, Swiss ATCA believes that this publication can serve you as an individual or as an organization in your country, though it might need some adaptions to be consistent with your operational and legal framework.

  1. ^ Just culture: A case study of accountability relationship boundaries influence on safety in HIGH-consequence industries, J. McCall & S. Pruchnicki, 2017
  2. ^ ‘Just culture:’ Improving safety by achieving substantive, procedural and restorative justice, S. Dekker & H. Breakey, 2016
  3. ^ Weder NZZ Fehlerkultur für mehr Sicherheit April 2016

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