{"id":439,"date":"2015-11-04T11:33:08","date_gmt":"2015-11-04T09:33:08","guid":{"rendered":"http:\/\/www.aviationadvocacy.aero\/blog\/?p=439"},"modified":"2019-07-23T11:47:58","modified_gmt":"2019-07-23T09:47:58","slug":"just-culture","status":"publish","type":"post","link":"https:\/\/www.aviationadvocacy.aero\/blog\/?p=439","title":{"rendered":"Just Culture"},"content":{"rendered":"In this article, Margriet Bredewold, CEO Co-Guard GmbH explains her concerns with\u00a0interpretations of the\u00a0‘Just Culture’ approach.<\/em>\r\n\r\nSafety management system-based operations are being introduced across aviation. Consequently, the discussion about \u2018Just Culture\u2019 is increasingly relevant. The European Commission, EASA and various trade associations have taken up the concept and are making a serious attempt to oblige operators, maintenance organisations and ground handlers to adopt a \u2018Just Culture approach\u2019.\r\n\r\nMost of these attempts involve regulatory frameworks, policies and signed declarations stating that \u2018honest mistakes\u2019 are accepted as long as reported, but cases of \u2018gross negligence\u2019 and wilful conduct are a matter for the courts.\r\n\r\nThe Just Culture concept provides managers a procedure to justify assigning culpability and disciplinary action (Hudson et al, 2008). However, is the baking in of judicial involvement the way forward? To understand the possibly very harmful effect of such interpretation of a Just Culture, we need to look more closely at human behaviour and human error in particular.\r\n\r\nOur industry accepts that 70% of accidents or incidents are down to \u2018human error\u2019 (UK CAA, 2014; Stevens and Vreeken, 2014). This can take many forms, ranging from \u2018pilot judgment and actions\u2019 and \u2018situational awareness\u2019 to \u2018unsafe acts and errors.\u2019: \u2018human error\u2019 as a hind-sight label for the root-cause of incidents and accidents.\r\n\r\nWe speak of human error if something unintended by the actor has happened; was not desired by a set of rules or an external observer; or that led the task or system outside its acceptable limits. Human error as such is defined by its (undesired) outcome. To detect \u2018error\u2019 means we have to be confronted by the (unwanted) consequences first. We then backtrack an event to a decision point where the actor could have acted differently. We assign the label \u2018human error\u2019 there (Dekker 2014; Hollnagel 2014).\r\n\r\nUnfortunately, the operator involved did not have the information of the eventual outcome at that point in time. Therefore, assigning responsibility for decisions or actions of which unintended consequences could not possibly have been foreseen is not meaningful, nor \u2018just\u2019.\r\n\r\nThe main difference between error and violation is intent. This difference is important, as it justifies many of our disciplinary policies across aviation. As with assigning error, we backtrack from an unfortunate action and compare this action to existing procedures. When we find a procedure was in place and had not been followed to the letter, we assign the label of \u2018violation\u2019 and base our judgement of culpability on this comparison.\r\n\r\nIn this way, we accept reducing human performance to either \u2018good\u2019 or \u2018bad\u2019 in relation to (unwanted) outcomes and the existence of and post facto adherence to rules and procedures. We conveniently strip a situation from its context \u2013 time pressure, lack of resources, customer demands, bad weather \u2013 which may provide valuable information to understand why a particular action or decision made sense to a professional in that situation (Dekker, 2014; Hollnagel, 2014). What is worse, we justify assigning culpability and serious legal and professional consequences to this simplification and misrepresentation of facts. Once formalised and legalised we call it a \u2018Just Culture\u2019.\r\n\r\nHowever, operators perform despite imperfect information, technology and context (Dekker, 2014; Hollnagel, 2014, Pepe and Cataldo, 2011). Most of the time, they get it right. Day-to-day performance adjustments are necessary to make our operations successful (Dekker 2014; Hollnagel 2014). So instead of focusing on the few times something goes wrong, conveniently simplifying complexity and ignoring the imperfect conditions to serve the courts, our focus should be on understanding the complexity (Hollnagel 2014) and the adjustments needed to support our front-end operators, reducing the chances that they end up in a bad situation where only split-second judgements save the day.\r\n\r\nClaiming an a priori right to punish, based on a hindsight label assigned through oversimplified models, will deepen the distrust already present in our industry and undermines any opportunity for learning. It risks undermining the great safety and performance achievements our industry has built up.\r\n\r\nInstead, when we are willing to change our attitudes and opinions about our operators by actually understanding what they do and understand how they make our systems successful we may already move towards that desired gain in trust.\r\n\r\nList of References<\/span>\r\nBredewold, G.M. (2014) A Socio-Technical Appraoch to Safety, European Rotorcraft Conference, Aeronautical Society, United Kingdom.\r\nDekker, S. (2008) Just Culture: who gets to draw the line?, Springer-Verlag London Limited\r\nDekker, S. (2013) Second Victim, CRC Press, New York\r\nDekker, S. (2014) The Field Guide to Understanding Human Error, third edition,Griffith University Australia\r\nGAIN working Group E (2004), A roadmap to a Just Culture, enhancing the safety environment\r\nHollnagel, E., (2014) Safety-I and Safety-II The Past and Future of Safety Management, University of Southern Denmark, Ashgate, England.\r\nHollnagel, E., J. Leonhardt, T. Licu and S. Horock, From Safety I to Safety II, European Organisation for the Safety of Air Navigation, www.eurocontrol.int.\r\nHudson, P. et al (2008) Meeting expectations: A New Model for a Just and Fair Culture, Society for Petroleum Engineers 2008.\r\nPepe J., and P. Cataldo (2011), Manage Risk, Build a Just Culture, www.chausa.org (2011)\r\nReason, J.(1990), Human Error, Cambridge University Press, England.\r\nSenders, J.W. and Moray, N.P. (1991) Human Error: Cause, Prediction, and Reduction. Lawrence Erlbaum Associates, p.25. ISBN 0-89859-598-3 at WIKIPEDIA 2015\r\nStevens, J.M.G.F., J. Vreeken (2014) The Potential of Technologies to Mitigate Helicopter Accidents Factors \u2013 An EHEST Study, NLR, Amsterdam.\r\nUK CAA (2014) EASA Rotorcraft Symposium, Cologne.","protected":false},"excerpt":{"rendered":"

In this article, Margriet Bredewold, CEO Co-Guard GmbH explains her concerns with\u00a0interpretations of the\u00a0‘Just Culture’ approach. Safety management system-based operations are being introduced across aviation. Consequently, the discussion about \u2018Just Culture\u2019 is increasingly relevant. The European Commission, EASA and various trade associations have taken up the concept and are making a serious attempt to oblige […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[18],"tags":[],"class_list":["post-439","post","type-post","status-publish","format-standard","hentry","category-safety"],"_links":{"self":[{"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=\/wp\/v2\/posts\/439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=439"}],"version-history":[{"count":5,"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=\/wp\/v2\/posts\/439\/revisions"}],"predecessor-version":[{"id":444,"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=\/wp\/v2\/posts\/439\/revisions\/444"}],"wp:attachment":[{"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=439"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=439"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.aviationadvocacy.aero\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}