Just Culture needs more than legislation!
by Virag Gulyas, Communications Officer at the European Cockpit Association (ECA)
About 18 months after its adoption and publication in the EU Official Journal, the new European Occurrence Reporting Regulation (EU Reg. 376/2014) is applicable across the European Union since 15 November 2015. This new, EU-wide legislation comes with the main purpose to launch a stronger Just Culture environment and a more robust reporting system across the aviation industry.
Just Culture: What’s the buzz?
However, there is a problem with overused words; they easily turn into empty catchphrases. During the 90’s, the industry was loudly promoting a “no-blame culture”. Today, the same industry talks about and yearns for a full-fledged “Just Culture”. But how can we ensure that Just Culture grows beyond being an engaging hashtag or a popular tagline? By knowing and implementing its core ingredients!
Just Culture has been widely discussed and experienced at different degrees in the aviation industry for years. It’s known to refer to a culture that attempts to balance an open and honest reporting system while not denying fair accountability. But Just Culture is more than an ambitious concept: it’s “the lifeblood of our aviation safety system” (Paul Reuter, 2015) and one of the most essential bricks in building a safe aviation. And wouldn’t that be the ultimate aim for the industry?
The aim is to create an industry where reporting mistakes isn’t something to avoid but is rather encouraged and even rewarded.
Thus, implementing a healthy reporting and feedback receiving cycle, where the fear of reprisal is overruled by the desire to identify and control potential safety hazards and enhance safety, is exactly what the advocates of Just Culture stand for.
The concept of Just Culture isn’t exclusive to the aviation industry. It – or at least the need for it – exists in industries such as healthcare, maritime, train transportation or the nuclear power. Yet, aviation –considered as one of the safest ones– a mistake often results in a large number of casualties turning the accident highly visible. All these features perfectly meet the criteria of media newsworthiness and give an excellent basis for a quick but long-lasting shame and blame. Add to this the overwhelming presence of social media and fast-paced information exchange, and the vital need for a protective and just reporting culture becomes palpable.
When the pilot’s community leaves its mark on legislation
This is where the new European Occurrence Reporting Regulation (EU ORR Reg. 376/2014) comes to play. Unquestionably, by bringing forward an extensive regulatory expansion, it’s a milestone event in the European aviation history. This new legislation, on which the pilot’s community left a major footprint, isn’t only crucial because it’s the result of years of hard work, in-depth dialogues, and a close cooperation between key aviation stakeholders and policy-makers, but also - and perhaps, above all - because it demonstrates a shared intention; the intention to create an industry where reporting mistakes isn’t something to avoid but is rather encouraged and even rewarded.
The new ORR defines Just Culture as “a culture in which frontline 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.” And the tools it lays down for implementing these principles are to ensure confidentiality in reporting; broaden the protection for everyone named in a report; extend the mandatory reporting list (including fatigue); introduce voluntary reporting schemes; and oblige airlines to adopt an internal policy describing their Just Culture principles.
Away from the jargons, closer to the pilots
But what if we step away from the heavy legal jargons for a moment and see what Just Culture really means and entails in the day-to-day operation?
“I’m strongly convinced that there are hundred thousand ways of implementing Just Culture. There is no ‘one-solution-fits-all’ approach here”, says Bert Bonke, Captain on B777 and accident investigator, to ECA. Regardless of the efforts for harmonisation, the challenge of ‘so many countries, so many customs’, might just fit here well. This is surely no surprise as different nationalities and cultural traits meet with different flying educations and career paths, and all these intensify by the diverse maturity of Just Culture at various airlines. Defining the core ingredients for a Just Culture, therefore, can offer a better understanding for pilots and managements alike.
The fear from repercussions remains the greatest burden when it comes to occurrence reporting. Peter Beer, accident investigator and president of the Austrian Pilot Association, is confident that “if you have to fear to lose your job if you open your mouth, it certainly won’t encourage anyone to report about things that might tarnish a ‘perfect’ reputation.” It’s obvious that to eliminate fear, the industry needs trust; not only between management and crew, but also between peers. Just Culture requires deliberate actions on management levels, thus, rightly so, should come as a top to bottom approach. Yet, as Johan Glantz ECA Technical Director & Just Culture Ambassador says, “the toughest blame you can get often comes from your colleagues.” Seeking someone to blame, and do that quickly is an ancient human reaction, but it’s a heavy burden on the aviation industry.
Especially, that shouldn’t be the case. We should accept that ‘human error’ is inevitable, and it is not only a convenient self-protecting phrase to hide behind but also backed up by science. Therefore, accepting mistakes should come as second nature to everyone, including pilots. In fact, reporting incidents should be the most basic act of commitment towards a secure aviation industry; knowing that reporting incidents can prevent accidents.
As opposed to the larger public, the industry knows that while accidents become history and attract attention, there are lots of events that don’t escalate into large-scale mishaps. What’s more, if treated well, they offer an excellent learning opportunity. This - the ability and the responsibility to learn from the mistakes to prevent others from facing the same challenges -, gives the second pillar of a universal Just Culture model.
As Glantz added: “Instead of making all the mistakes yourself, learn from someone else’s.” But encouraging the willingness of reporting serves little purpose unless it becomes a two-way road. “We’re going to hit a brick wall if we don’t give feedback to people. No feedback is ‘a killer’ for reporting”, says Rudy Pont, Belgian pilot and member of the ECA Flight Data Working Group, who leads cross-industrial workshops on Just Culture.
With this, the model gets clearer: on the one hand, people should feel safe to report; on the other hand, they need to know what is going to happen with their report and what can be done better. As the former navy, today commercial airline pilot and ECA Flight Data Working Group Chairman, Renault Bosma argues “in a Just Culture, the ‘why’ should be more important than the ‘what’ and the ‘who’; and for that, we need to learn to ask the right questions.”
Pilots are at the front-line of the system: if they don’t report their events, inaccurate decisions or mistakes, the whole system will remain a nice theory.
‘Just’ doesn’t mean immunity
We all agree that having a Just Culture doesn’t mean immunity. It means that “as long as you are doing your job, you should not be punished”, says Bonke, who upholds that finding out the intention in any incident is a game-changer. Accountability can’t and shouldn’t be overlooked. But the spectrum for ramifications should be broader: nobody should decide between reporting and not reporting out of fear; nobody should fear of losing his job for reporting.
Thus, regardless of where you are from, or what precise definition you would add to Just Culture, the fundamental ingredients are universal: Just Culture requires the clear synthesis of building a confident trust across the industry, understanding the intention, and having the ability to learn from mistakes.
The European regulation, therefore, is a prodigious step towards an even safer aviation industry. But then again, no written legislation alone can bring a tangible impact. To ensure and maintain that Just Culture grows beyond a popular catchphrase, the industry needs pro-active role-models, who are committed to change and are ready to continuously stimulate the environment. Pilots are at the front-line of the system: if they don’t report their events, inaccurate decisions or mistakes, the whole system will remain a nice theory.
Because, as Glantz says, one thing is sure: “It takes two years to build up an organisation with Just Culture reporting, but it takes only an hour to break it down!”