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In Just Culture we trust

Just Culture is about learning, which means Just Culture is about the reflection on what happened and why it happened. Just Culture means to explain the incident or event not to find the sole root cause.

On the contrary, blaming means to narrow the event down to one single view, without looking for a good explanation.

Just Culture acknowledges that failure is inevitable in a complex system. If a failure is happening, Just Culture will try to explain how the system can be improved in the aftermath of the event. The ideals of Just Culture will be achieved with collaboration and understanding of all views within the ATM system.

Allowing the view from below and at the same time giving the view from above the means to respond to failure is a difficult balance... BE AWARE this is a real big group that includes stakeholders even outside your ANSP!

The following feature articles on Just Culture were published following the conviction of an Air Traffic Controller in Switzerland mid-2019. They seek to trigger thoughts and ideas for how to proceed.

Just Culture: Are we sustaining a false belief?

By Sidney W. A. Dekker, currently a professor at Griffith University in Brisbane, Australia, where he founded the Safety Science Innovation Lab. He is also Honorary Professor of Psychology at the University of Queensland. He flew as First Officer on Boeing 737s for Sterling and later Cimber Airlines out of Copenhagen. In 2004, he wrote […]

Just Culture: Learning or Punishing?

By Job Brüggen, Safety Officer of LVNL (Air Traffic Control The Netherlands). Our feature articles on Just Culture, triggered by the conviction of an Air Traffic Controller in Switzerland, aim to trigger thoughts and ideas for how to proceed. This article is written as a personal opinion of the author and does not necessarily reflect […]

Just Culture: Where are we going now?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just Culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed. To describe one […]

Bridging the gap – are we fighting windmills?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed. This article explains […]

Is the Justice System ready to adapt to a more connected and interrelated world?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed. In the second […]

Are we burying Just Culture for good?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just Culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed.  In the first article […]

IFATCA Just Culture Guidance Material

Just Culture has been at the forefront of IFATCA’s professional and legal debates for many years. This guidance material will assist Member Associations in preparing and sustaining Just Culture in their organisations.

Just Culture Toolbox

Co-authored by the ATM Partners for Just Culture: ATCEUC, CANSO, ETF, IFAIMA, IFATCA, IFATSEA.

SwissATCA Just Culture Manual

SwissATCA's comprehensive manual on Just Culture.

Italy, Naples International Airport, airplane and Control Tower

Making aviation safer by not blaming the human, but by looking into the system

How to implement a Just Culture?

This is one of the pressing questions that many people ask. Implementing and maintaining a Just Culture is not a straight forward process that can be captured in a checklist or procedure. There is little or no shortcuts to understanding the concepts and ideas behind Just Culture.

You, your colleagues, your organisation and everybody involved need to participate in the process and understand what it means to put justice over power, to allow different perspectives, to be curious about how things work, to listen to the view from below, to explore new ways of accountability and to develop explanations of system behaviour.

Just Culture takes time and commitment.

Just Culture is about improving the safety of the aviation system. It is about promoting a culture of trust where controllers and other personell can openly report and share information without fear of consequences. This results in a more robust safety culture that ultimately benefits all airspace users.

JC is about the safety of the system and is defined as follows:

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In a Just Culture environment, all reports and incidents are treated to find explanations on how to improve the system, instead of finding the culprit or the causes for the incident. As it is stated in ICAO Annex 13, 3.1, "The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability."

(ICAO). 2016. Annex 13, 11th Ed. Montréal, Canada: ICAO.

How to promote and implement JC in your ANSP/organisation

These points are just a few examples, but provide a good starting point for the promotion and implementation of Just Culture inside your ANSP.

Implementation of a Just Culture inside your ANSP

(not everything will be solved easily and not all aspects will be realised right from the beginning).

1

Verify legal aspects in your State, talk to you national authority and try to influence your legal national framework to support a Just Culture implementation

2

Reporting policy and procedures should be in accordance with IFATCA policies (dissemination, cooperation, confidentialy, protection of the safety data). This is necessary to gain trust inside and outside your ANSP. The reporter is a big source of information for your investigation process in this type of reporting; data protection is essential to get the most out of the report and to improve your system

Some more detailed steps on the way to implement a Just Culture:

1

Systemic investigation vs individual focus

The focus of an investigation within Just Culture should be on explaining why things happened as they happened instead of looking for probable causes of the incident and identifiying people responsible for it. This would give you an in depth knowledge on how the system is functioning and to improve the system on all levels of it.

2

Forward vs backward thinking

The investigation should look into the future evolution of the system, not into loopholes from the past. The aim should be how to improve the system, without looking for a culprit. No one is coming to work to harm people.

3

Learning opportunity vs blame attribution

An incident is a free lesson learned for the system. When incidents are staying inside the organisation, the organisation will get the possiblility to learn. Instead if the incident is going outside of the ANSP, then this will hinder the possibility of learning. If the incident is treated public, then a different power is working against learning.

4

Confidential reporting

Build up a confidential reporting system. This will be an important part in building up a Just Culture. The reporter needs to be anonymized – only the investigator will know the name – as it is not important who was involved in the incident for the purposes of the report.

5

Data protection

The data derived from reporting needs to be protected from outside of the company. As soon as the incident will go outside of the company it will become a different reality.

6

Just culture is to the service of safety. Not a means of social control or a disciplinary mechanism.

7

To achieve the ideals of a Just Culture will require collaboration and understanding of others views.

8

Just Culture is perishable. It requires hard work to be sustained by continued commitment to the ideals and by continuous dialogue. Just culture is not simple. Each event where Just culture is used will have its own unique context.

In a Just Culture environment, all reports and incidents are treated to find explanations on how to improve the system, instead of finding the culprit or the causes for the incident. As it is stated in ICAO Annex 13, 3.1, "The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability."

First steps for the implementation of a Just Culture in your organisation!

Start by convincing your ANSP to endorse a Just Culture policy, ideally signed by the ANSP Executive Board (IFATCA’s Just Culture Policy model(s) — or use best practices from other ANSPs)

Engage staff representatives and all staff – not only from the operational units

Try to get Just Culture training – IFATCA EVPP can help you organise a Think Safety Workshop with a focus on Just Culture 

Give staff training on how to report an incident

Create an awareness programme for your ANSP on the topic of Just Culture: leaflets, advertising, posters, etc.

But keep in my mind

these are just the first steps!

Let’s take it outside!

Bringing JC to the greater world.

Your regulator – talk to them about Just Culture and/or invite them to one of the IFATCA Think Safety courses 

Be open and tell them or teach them why a Just Culture is important to improve aviation safety 

They need to build the regulatory framework for Just Culture. We all need to work on this!

CONTACTUS

Feel like digging in and you’ve got nothing better to do?

Check our references.

If you are interested in getting more information and training for Just Culture in your organisation – not only for ATCOs – try to organize the Safety Training course at your place. IFATCA will support you with trainers and also in the discussion to promote Just Culture in your ANSP.