Just culture

London
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Eurocontrol wants to spread an open incident reporting system across Europe and beyond, so that safety can benefit

For years the airline industry has been working to develop a “just-culture” incident reporting system within which pilots, mechanics and others can report errors or close calls without being subject to a disciplinary process. Only if safety has been wilfully disregarded does blame or retribution enter the equation.

Eurocontrol wants to give a boost to just-culture reporting in the European air traffic management (ATM) community, and is threatening to name and shame states that are making no moves to set one up. The agency has become frustrated at the slow progress of ATM incident reporting in Europe since the accidents at Milan Linate and Uberlingen in 2001 and 2002, both of which were ATM-related and both of which led to fierce retribution against individuals when hidden systemic problems were the cause. The subsequent review of ATM safety identified the need for a healthy incident reporting culture as one of the seven areas requiring attention.

Eurocontrol is sailing into uncharted waters, since it is not the aviation community that is the problem, but national judicial systems. It is therefore addressing an area where it has no direct influence, and is pleading with transport ministers to try and convince justice departments of the merits of the just-culture case.

There is already international backing for the introduction of improved reporting measures. The European Commission’s directive on occurrence reporting in civil aviation is gradually being incorporated into national law and the International Civil Aviation Organisation strongly supports Eurocontrol’s initiative in particular, and the concept in general. ICAO’s Annex 13 spells out that the purpose of accident investigation is to find the cause in order to prevent future occurrences, not to apportion blame.

In many states, however, the introduction of legal protection for voluntary occurrence reporting is controversial, as it is argued that there are other professions that would then require similar protection from the law, creating the need for a major review of national penal codes. The answer is that just-culture protection should only apply where safety management is paramount. Aviation safety performance improvement in countries that have adopted just-culture reporting testifies to its effectiveness, and there is no reason why safety incident reporting in non-aviation industries should not also benefit.

Where there is no just-culture reporting system, individuals tend to put their own immediate interests first – like keeping their job, or promotion, avoiding disciplinary action and the opprobrium of workmates, any of which could result from reporting an error that will probably go undetected, but which could have been dangerous. The answer is to change the reporting culture so that admitting and reporting individual errors is seen positively because of the benefits it brings to the system – especially where the system may be a part of the problem. This encourages mutual respect and a desire to work together on solutions instead of trying to bury problems without solving them.

Eurocontrol realises that there is a clear need in many states for national legislative support for non-punitive reporting and assurances of confidentiality. It believes this can and should be based on existing ICAO, Eurocontrol and European Union standards and regulations adopted locally. A major education and awareness campaign is also needed to publicise established best practice.

Meanwhile, Eurocontrol has been trying, through its own rule-making processes, to create obligatory provisions whereby member states require their air navigation service provider (ANSP) to implement formal safety occurrence reporting and assessment systems, and to report the resulting data centrally to Eurocontrol so that endemic problems can be identified and trends recognised. While laudable, the process is taking too long and some states have not even begun this work. Even in states that have the goodwill and motivation of ANSPs, the system is endangered where there is no appropriate modification to the legislature. Without this, the system can be destroyed by a single bad experience.

Only when free reporting practices are introduced in European ATM – and eventually globally – will the travelling public be convinced that safety, rather than protecting individuals, really is the priority.