Just Culture George Monteiro Principal Airworthiness Surveyor Just Culture in Aviation Safety Key Topics What is a just culture Impact of organisational culture on safety performance Just reporting informed and learning cultures ID: 768059
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Just Culture George Monteiro Principal Airworthiness Surveyor
Just Culture in Aviation Safety: Key Topics What is a just culture? Impact of organisational culture on safety performance Just, reporting, informed and learning cultures Legislation, guidance and policies building trust Assessing and measuring: determining culpability Just Culture and safety improvement
Just Culture in Aviation Safety: Key Topics What is a just culture? Impact of organisational culture on safety performance Just, reporting, informed and learning cultures Legislation, guidance and policies building trust Assessing and measuring: determining culpability Just Culture and safety improvement
Not entirely a new idea A fault revealed voluntarily will be treated leniently but a fault concealed may lead to serious consequences for the workman, not to mention the pilot Hurricane production 1940
In a just culture errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action A learning culture means that an organisation is able to learn from its mistakes and make changes. It will also ensure that people understand the SMS processes at a personal level Safety Culture What is a Just Culture? Safety Culture – Just Culture – Learning Culture? How people feel – Psychological
Just Culture: Reasons to Report, or not….. YES – Report it! Don’t want aircraft to crash I know I’m supposed to Somebody saw me It might happen again I might get thanked The system will support me It’s the law Easy to complete a report NO – Hide it! I might get fired Nothing will change I’ll look foolish I might lose my Licence Nobody noticed It’s unimportant It’s too difficult
What is a Just Culture? - Reminder Safety Culture Organisation collects and analyses relevant data, and actively disseminates safety information. Organisation is able to learn from its mistakes and make changes. It will also ensure that people understand the SMS processes at a personal level. Organisation and the people in it are capable of adapting effectively to changing demands. Errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action. Cultivating an atmosphere where people have confidence to report safety concerns without fear of blame. Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting.
Legislation, Guidance & Policies Building Trust: Legislation & GuidanceGuidance material CAP382 The Mandatory Occurrence Reporting Scheme further amplifies this protection of the reporter A Statement by the CAA Chief Executive describes: Assurance regarding prosecution Confidentiality of reports Possible action by employersAction in respect of licencesJust culture Just Culture Definition Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated www.caa.co.uk/cap382
Assessing & Measuring: James Reason – Culpability Model 9
Assessing & Measuring:Patrick Hudson – Just Culture Model 10
Assessing & Measuring: FAiR2TM System – Flowchart Analysis of Investigation Results FAiR Version 2.0 - March 2015 © 2015 Baines Simmons Limited
Just Culture & Safety Improvement: Maintaining Focus Contributing Factor Contributing Factor Contributing Factor ERROR EVENT Wrong Screws Window Blow-out Contributing Factor
Just Culture & Safety Improvement: Effects of an ‘Unjust Culture’ Employees unlikely to report Information source dries-up Unsafe practices driven underground Reputational damage – whistleblowing Regulatory compliance failureUnaware of organisation’s risks – no mitigationSerious Incident or Accident?
Why has Just Culture become so Important? The SMS Helicopter Safety Promotion Safety Policy & Objectives Safety Risk Management Safety Assurance Safety Culture Safety Culture Remember this?
Understanding of SMS:Practically, What is a SMS? Managing your risks to prevent the ‘bad’ things happening Accepting that things will go wrong but minimise the consequencesA means to identify and understand your safety risks
Questions????