It is only natural that people and organizations would be less willing to report their errors and other safety issues if they are afraid of punishment or even prosecution
Just culture

Just Culture achieved prominent recognition in the European Union (EU) last month, and there are new provisions calling for the protection of safety-related information anticipated to be adopted by the ICAO Council very soon. But, it is what you do with the tremendous amount of data that a just culture enables to be captured, through various mandatory and voluntary reporting systems, that magnifies its positive effect.

“The new EU regulation is about encouraging aviation personnel to tell their employer when things aren’t working well. It isn’t always that someone has made a mistake, it’s that something hasn’t worked out as expected on this occasion. They need to feel that they are being supported by their employer and that this information is useful and will be used to improve things,” said U.K. Civil Aviation Authority’s Performance Based Regulation Safety Data Lead, Sean Parker.

Beyond Europe, global standards beckon for Just Culture [See box Explaining Just Culture]. In October, ICAO member states filed their responses to proposals that include the addition of Safety Culture to Annex 19 of the Chicago Convention. Safety Culture is a broader concept, in which Just Culture is part. Just Culture enables a Safety Culture to exist. Following the anticipated final approval in March 2016, ICAO member states could be required to adopt Safety Culture through the amended Annex in November. Experts foresee a 2018-2020 timeframe for Safety Culture’s incorporation into the domestic regulation of the 190 ICAO member states.

Safety Culture and the need to protect safety data and safety information, collected for the purpose of maintaining or improving safety, was a notable theme at the second ICAO High Level Safety Conference, held earlier in 2015 in Montréal. It was agreed that quick progress in this regard is critical for the improvement of aviation safety.

“It is only natural that people and organizations would be less willing to report their errors and other safety issues if they are afraid of punishment or even prosecution,” noted Gilberto Lopez Meyer, IATA Senior Vice President, Safety and Flight Operations. “These protections are essential for the ongoing availability of safety data and safety information, and forms the basis of a Just Culture.”

The adoption of Just Culture will not only widen the array of data sources that can feed into a company or industry-wide predictive tool, but also increase the quality of the data provided. It is the predictive data analysis that can deliver more than simply local improvement at an airport or maintenance hangar, which a conventional mandatory reporting system for the immediate line managers may do.

Such predictive analysis can also be useful for accident prevention and investigation. A diversity of data to analyse is good because accidents are, “always a confluence of a variety of different factors, which nobody would ever have guessed would have come together at the same time,” IATA General Counsel Jeffrey Shane said.

The quantity of data produced from mandatory and voluntary reporting systems cannot be understated. Legal firm Pillsbury Winthrop Shaw Pittman Partner and Head of its aviation practice, Kenneth Quinn said: “You’re getting 10,000 bits of data from the widest possible variety of sources from airlines, as well as voluntary occurrence reports, [and] your getting it from repair stations.” And all of that can go into powerful computers.

“A big benefit is you can benchmark against other people,” Quinn said. “If you have five engine shutdowns over the course of a year and airline B has none then you have a higher than normal average of in-flight shutdowns, how are you monitoring things?”

Quinn points to the work the United States’ Federal Aviation Administration has done. All of that occurrence data, Quinn said, “goes into very powerful computers…and you take that and implement mitigation strategies to correct that, its having demonstrable safety benefits.” Because of the FAA’s work, Quinn explained that other authorities are examining the potential for such mass data reporting based predictive technology.

At the European Commission’s Aerodays 2015 conference in London in October, the European Aviation Safety Agency talked about its big data safety project that will spend about 31 million euros from 2015 to 2017. The project will seek to demonstrate an ability to predict an unsafe situation.

The adoption of Safety Culture, and by default Just Culture, by ICAO, will, however, present a challenge to some member states and access to all the diverse data that could make a difference could be hindered.  “We recognize there are sovereign legal systems that regard an accident as, in the first instance, something that is a potential criminal act,” said Australia’s Civil Aviation Safety Authority’s Associate Director of Aviation Safety, Jonathan Aleck.

Australia is not a country that begins with a criminal investigation, Aleck highlighted. Its airlines have adopted Just Cultures and in its latest annual review for 2015, Qantas said: “We are proud of our strong, ‘just culture’ of reporting and our dedication to learning from our experiences. And we strive to maintain an environment that encourages trust and confidence in our people to report hazards and incidents and suggest safety improvements.”

Nations whose airlines do face a criminal investigation team, whether they have Just Cultures or not, according to Aleck. He said: “In some jurisdictions there is a strict program [of aviation regulation]. The idea of just culture doesn’t fit well with those kinds of regimes, where the first people on the scene are often criminal investigators.”

Before the likely cause of the 31 October crash of Metrojet flight 9268 had been identified as a bomb, the Russian authorities initial announcement regarding its investigation was the start of a criminal one. The concern is that people who know what led to an accident will say nothing for fear of prosecution, when their information could help stop potentially fatal incidents from occurring again.

Shane is positive about changes to national legislation where Just Culture is not already codified following the expected ICAO March decision. He said: “The benefits can be demonstrated so powerfully that I expect [legislatures to adopt it in the next few years].”

The expansion of Just Culture has grown momentum. For those that have or are employing it, they find that it delivers new insights into how things go wrong. But, questions remain as to how far nations, whose instinct is to investigate possible criminal action first, can succeed in gaining all the possible benefits from the additional information that becomes available.

IATA Member & External Relations, ICAO, Director, Michael Comber sums it up simply. “It’s a tremendous advantage to have people come forward and speak because it’s the best way to prevent as well as figure out how [accidents] happened.” And that points us in the direction of improving safety.

Explaining Just Culture
The definition of Just Culture is an open way of working in which employees are not punished for decisions taken in good faith and commensurate with their experience and training. The employees can report mistakes, by them or others, and know that that information will feed into the safety management system.

However, gross negligence, willful violations and destructive acts are not tolerated.

Just Culture has been required within the EU since November under its regulation 376/2014 that also renews earlier mandatory reporting law. For Just Culture, the EU is requiring that organizations have protection for the reporting staff member, and for persons mentioned in the report, rules for confidentiality, and protection from an employer.

Prior to the European law coming into effect, a European declaration in favor of Just Culture was published in October. The declaration is supported by the Airports Council International, European regions airline association, European Cockpit Association, Aircraft Engineers International, IATA, and other aviation organizations.

As well as European efforts to implement Just Culture, this non-punitive reporting system was included in the Australian Civil Aviation Safety Authority’s new regulatory philosophy published in 2015. Prior to Australia’s CASA action, the United States, New Zealand and the UK had their own rules in place.