Just Culture informs the management of three types of behaviours: human error; at-risk behaviour; and reckless behaviour.
There are a number of Just Culture models available to assist in identifying the individual behaviour and to guide management response decisions. Advanced models include system factors such as procedures, training and management.
Here are the normal responses to the manageable behaviours.
|
Behaviour |
Description |
Response (options) |
|
Human Error |
Unintentional (e.g. slip, lapse) |
Console Remedial action |
|
At-Risk |
Knowing deviation from a rule, procedure or standard practice Aware of risk, though believed to be insignificant or justified Intentional action but unintended outcome |
Coach Remedial action |
|
Repetitive At-Risk |
Choice to continue to deviate from rule, procedure or standard practice |
Remedial action Punitive action |
|
Reckless |
Conscious disregard of substantial or unjustifiable risk Intentional action with probable outcome (though individual may overestimate own control) |
Punitive action |
Just culture implies a ‘duty of care’ of aviation participants to follow procedures and rules, and to avoid causing harm or unjustifiable risk. Decision-makers should strive to strike the right balance between accountability and learning in responding to events, in order to create an environment where people feel comfortable reporting errors, hazards, and occurrences. Just Culture supports learning from events through enhanced sharing of safety information to prevent future accidents.
The CAA applies Just Culture principles as part of our proactive safety activities, and also in our response to safety deficiencies and risks.
Proactively, the CAA is beginning to assess safety culture as part of our oversight of participants’ Safety Management System (SMS). While SMS provides an effective framework and processes for safety, good safety performance will only be achieved if underpinned by a positive safety culture. The indicators we look to when assessing safety culture include the nature and extent to which:
The CAA aims to provide feedback to participants on the above to assist them on the journey from a ‘Present and Suitable’ SMS to one that is ‘Operating and Effective’.
The CAA also employs Just Culture principles in our response to safety deficiencies and safety occurrences.
We first seek to examine the nature of the event or breach, the level of risk, the causes, the systems in place, and the behaviour of the people involved. We examine whether the participant self-reported the event in a timely and fulsome manner, whether the matter is part of a pattern, and the extent to which those involved accept accountability and are willing to learn or change. In addition to these factors the CAA must always consider what is best in the public interest. In doing so, our application of Just Culture will consider the wider impacts including enhanced reporting, which benefits overall system safety.
Our application of Just Culture is as follows:
If an aviation participant reports their involvement in an incident or Rules omission/breach in a complete, accurate and timely fashion then the CAA will apply just culture principles in its response. Where there’s no self-reporting, or there is evidence of repeated at-risk behaviours or recklessness, then the protections of Just Culture will not apply.
There are three challenges to the CAA’s application of Just Culture which need to be acknowledged. These relate to:
When there is an accident involving harm, particularly death or serious injury, this consequence becomes a significant factor when determining the appropriate regulatory response. Action to hold people to account may be required in the public interest. However, in reaching this decision the CAA will weigh the benefits of addressing the specific event against other actions which may have wider or more enduring system safety benefits. This challenge should not be used as a rationale for participants to refrain from reporting occurrences which do not involve harm.
Advice from industry representative bodies is that the lack of Just Culture provisions in legislation is a barrier to full adoption by participants, including open reporting. While the CAA acknowledges that this may be the case in some areas, it is unfortunate that this is being used as justification for not providing occurrence information which might assist in preventing a future accident. Nevertheless, work is underway in this area. The Civil Aviation Act Review initiated in 2014 investigated the barriers to full reporting of occurrences, and assessed options to create an environment for free and open disclosure of information. This work has been included in the drafting of the Civil Aviation Bill. The CAA has proposed the inclusion of Just Culture principles in this Bill, including how reported safety information is used.
When the CAA is required to take strong regulatory action in the public interest the full facts of the case, including the application of Just Culture principles, is often not visible to the wider aviation sector and the public. There is good reason for this including our obligations under the Privacy Act. In this vacuum the industry and public are often provided with a one-sided view of what has taken place, which may not explain the reasons and rationale for the regulatory response. This can erode the sector’s confidence in the CAA’s application of Just Culture and affect occurrence reporting.
The CAA intends to address this in two ways.
First, we will provide information on the number of prosecutions taken annually. This information will show that the CAA has not historically taken any punitive action against participants that self-report in a timely and comprehensive manner. Second, where appropriate the CAA intends to provide additional detail regarding significant regulatory action taken so that the application of Just Culture principles is more evident.
