A think piece on Just Culture from Greg Hardman, British Airline Pilots’ Association (BALPA), Aircraft Design and Operation and Aerodrome Ground Environment (ADO-AGE) Study Group and member of the NW Local Airspace Infringement Team (LAIT).
“Just Culture” is widely accepted throughout the commercial aviation sector in the UK and across Europe. Ask any UK commercial pilot and they will almost certainly be able to share a basic understanding with you. So what is a “Just Culture”? Why is the CAA operating it? What are the benefits of a “Just Culture” and why should you embrace it? This article seeks to answer these questions and provide you with a brief introduction.
“Just Culture” was devised by Prof. Sidney Dekker, a Human Factors and Safety expert and former commercial airline pilot. It is essentially an evolution of a “no-blame” culture – fundamentally a culture where individuals are not punished for their actions, omissions or decisions if these are commensurate with their experience and training (i.e. they are honest errors) but where gross negligence, wilful violations and destructive acts are not tolerated. A “Just Culture” has a notional line in the sand between acceptable and unacceptable behaviour.
So why is this relevant to aviation?
Commercial aviation is, generally, perceived as safe and yet aviation itself is undoubtedly a high-risk activity. Safety is a result of successfully managing risk. Where systems and sub-systems fail or lose the ability to manage changes or unexpected events in a timely manner, serious incidents or accidents can occur. As a pilot you are a hugely important “system” involved in aviation and you are the ultimate manager of risk on-the-day. Despite everyone’s best efforts, sometimes systems (including us) do struggle to cope and so make mistakes or fail. When this happens it is incumbent on us all (including the CAA) to review, investigate and to learn lessons to improve safety in the future and to try and prevent a repetition of the same error chain. This is where “Just Culture” comes in.
International surveys have revealed that many incidents go unreported because those involved are fearful of potential consequences; in general aviation this tends to be a fear of regulatory authority consequences. It is human nature to not want to be blamed for making a mistake, but it is our responsibility as licence holders to admit these mistakes in order to make aviation safer.
So why is the CAA so keen to operate a “Just Culture”?
Consider one example of a mistake that the CAA regularly have to deal with – airspace infringement. Many tools are available to help pilots avoid infringements – lower-scale charts, moving maps, listening squawks, thorough pre-flight planning and free online tools to aid this (such as SkyDemon Light) etc. – and yet the number of reported airspace infringements continue to increase. Where an infringement occurs the CAA investigates under the “Just Culture” process. Radar data is gathered, pilot and ATCO reports are reviewed and further information may be sought directly from the individuals to supplement these. Unfortunately in a large proportion of these incident investigations the pilots refuse to participate, anecdotally for fear of consequence. Not only does this hamper the investigation, it also prevents the individuals from learning any lessons from the incident that would help them become a safer pilot in future – it prevents them reducing future risk.
Under the “Just Culture”, any CAA investigation is not looking to apportion blame for an incident – it is seeking to establish the facts to fully-understand why the incident occurred and what remedial training/education actions can be taken to prevent a repeat. The best way you can help is to engage with the investigation and be open and honest. Your “Threat and Error Management” (TEM) will also be looked at – did you do everything you could to prevent the infringement? Were you using all of the tools at your disposal? Did you react as you would be reasonably expected to on the basis of your training and experience? The investigation will look at all the causal factors of the incident and what actions can be taken to ensure it does not happen again. This could be anything: improving the provision of information to pilots, correcting mistakes with information already provided, providing additional services to prevent reoccurrences or providing assistance in re-educating pilots where genuine mistakes have been made. If you have not been grossly negligent or deliberately violated the airspace, but have made an honest mistake, then punishment should not be necessary.
But what’s in it for me?
“Well that’s great, a ‘Just Culture’ helps the CAA investigate incidents, but what’s in it for me?” you may be thinking. By operating a “Just Culture” the CAA is hopeful that general aviation pilots will embrace an open and honest reporting culture. As evident in the commercial sector, where this happens and the number of reports increase, the ability of the regulator to understand what underlying factors exist that can be addressed also increases, aviation gets further de-risked and, as a result, safety improves which benefits us all.
For “Just Culture” to be effective, it relies on everyone to accept it from the top down. The CAA has committed to operating a “Just Culture”, including in any safety investigations it undertakes. This website is being continually improved to provide you with feedback to demonstrate this.
In addition to the publicised incidences where pilots have been wilfully negligent and so have been dealt with accordingly under the court system, there are also examples of incidences where individuals were not dealt with punitively, but the mistakes were acknowledged as “honest”. All of this is to try and show you the benefits that have been realised by operating a “Just Culture” and, hopefully, to encourage you to report hazards (before things go wrong) and occurrences (after they go wrong) openly and honestly. Arguably the former is more important as this allows the Regulator to look at potential weaknesses in the system and strengthen these before they lead to incidents.
In summary
A “Just Culture” is one where honest mistakes are accepted, but wilful violations are not. Due to the non-punitive reaction to honest mistakes, safety reporting increases. This allows identification of further, hidden, risks and allows these to be mitigated, improving safety for all. Where investigations are carried out by the authority you can have confidence that “Just Culture” will be abided by and so can engage fully without the worry of punitive action for making an honest mistake. The improvements to safety that result from a wholesale embracing of “Just Culture” are for the benefit of us all – this is the fundamental driver behind “Just Culture” and is why we should all embrace it.
Hopefully this article has provided you with a basic understanding of “Just Culture”, why the CAA has implemented it, why it has been widely accepted in the commercial sector and why you should support it. There is a lot more information out there and some links are provided below – you are encouraged to seek this and educate yourself so that you have the confidence to submit reports without fear of retribution and the benefits of “Just Culture” can be realised by the entire general aviation community. As a reminder CHIRP remains available as an independent and confidential reporting system which complements the CAA’s Mandatory Occurrence Reporting system.
