01 Budapest JC IFATCA View on Just Culture · Just Culture internal rules should include, amongst...

IFATCA View on Just Culture �and possible way forward

Zeljko Oreski IFATCA EVP EUR

Zeljko Oreski, IFATCA Executive Vice-President Europe

IFATCA View on Just Culture �and possible way forward

Content:   About IFATCA   Basic truth   IFATCA Definition of Just Culture   Aim of a Just (Safety) Culture   Latent Conditions   The 4 pillars of an SMS+   The Reality of JC for IFATCA members – Survey 2015   EU Regulation 376/2014 – a way forward; a game changer?   Risk?   Corporative Just Culture Declaration   Conclusion


About IFATCAIFATCA is a worldwide organization representing more than fifty thousand air traffic controllers in 127 countries. The goals of the Federation are: ü  To promote safety, efficiency, and regularity in

international air navigation. ü  To assist and advise in the development of safe and

orderly systems of air traffic control and new procedures and facilities.

ü  To promote and uphold a high standard of knowledge and professional efficiency among air traffic controllers.


About IFATCAIFATCA is a worldwide organization representing more than fifty thousand air traffic controllers in 127 countries. The goals of the Federation are: ü  To closely cooperate with international and national

aviation authorities and institutions concerned with air navigation.

ü  To sponsor and support the passage of legislation and regulations which will increase and protect the safety of air navigation.

ü  To strive for a world-wide federation of Air Traffic Controllers. Associations.


About IFATCAIFATCA is a worldwide organization representing more than fifty thousand air traffic controllers in 127 countries. IFATCA Executive Board


IFATCA View on Just Culture � and possible way forward

One basic truth

… so even controllers make mistakes!

Mistakes are human Controllers are human


TPM 2015 page 4 2 4 7 LM 11.2.1, JUST CULTURE, TRUST AND MUTUAL RESPECT IFATCA policy is: A Just Culture in Accident and Incident Investigation is defined as follows: “A culture in which front line 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, willful violations and destructive acts are not tolerated.” WP 156 Kathmandu 2012 and WP 159 Istanbul 2007

IFATCA definition of JC


•  Inpar'cular,theregula'onaimstoincreaserepor'ng.

•  Howisthesuccessofthisregula'ontobemeasured?

•  Intermsofthefrequencyofunsafeeventsmanifes'ngthemselvesa>erthereportshavebeenactedupon?

•  Intermsofanincreaseinthefrequencyofreportsfiled?

Aim of a Just Culture


Create a trustful environment within an ANSP/company, where controllers/workers feel confident enough to report any occurrence that may affect safety, even if they feel it was “their mistake”.



Latent Conditions

Economical Pressure

Training

Unclear procedures On – time

Performance

Existing SOPs

CAPACITY

FATIGUE


The four pillars of an SMS+

1995 2000 2005 2007 2009 2010 2011 2012

ICA

O

EU

RO

CO

NTR

OL

FSF

IF

ATC

A

AGAS SAFREP

Delta case

1998 2001 2002 2004

2003/42 996/2010

JC TF MODEL POLICY

ROADMAP JC


The Reality of JC for IFATCA members – Survey IFATCA surveyed its Member associations during September 2015. The questions were: Who had and who had not JC in place ?

And if they had it, if Controllers were treated accordingly its principles?

If not : What were the problems preventing JC to be implemented in their ANSP?


The Reality of JC for IFATCA members – Survey The results from the European Associations: •  Most of our membership participated in the survey so far

(35 out of 45) •  Of those , 6 replied they did not have yet JC officially in

place (17%) (Belgium, Bosnia& Herz. Ireland, Spain, Israel and Georgia)

•  But 13 said it is not working (37%)


The Reality of JC for IFATCA members – Survey

AFM15%

AMA6%

ASP5%

EUR14%

MISC2%

NOREPLY58%

REPLIES

0

10

20

30

40

50

60

70

80

90

AFM AMA ASP EUR

INPLACE NOTinplace work notworking


IFATCA ECA ECTL prosecutor initiatives

Corporate Level Arrangements

on JC

EC Institutional affairs -

Helpful or just ticking boxes?

Reg.376/2014

Have we reached the ideal situation?


Experience with Just culture from �an IFATCA point of view


Experience with Just culture from �an IFATCA point of view - examples


It’s all about risk? But what is risk?


Corporative Just Culture Declaration

AIRPORTS COUNCIL INTERNATIONAL

ЮАЕА ASSOCIATION Of EWOKAH AIRLINES

AIRCRAFT ENGINEERS INTERNATIONAL

Τ A* OSO A I R P O R T R E G I O N S C O N F E R E N C E oirport services association

AeroSpace and Defencc Industries

Association of Europe

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C ̂ A Piloting CwO Safety European Cockpit Association eurĎpean regions airline association

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EUROPEAN CORPORATE JUST CULTURE DECLARATION1

Safety is of paramount importance to the public but also to the aviation industry.

Safety is not only a legal requirement but also a key contributor to sustainable business. Any entity in aviation has therefore a responsibility to maintain and improve safety.

Staff working in the aviation industry, at all levels, have a safety responsibility and are key to a safe system.

A safe aviation system requires events that affect or could affect aviation safety to be reported fully, freely and in a timely manner as needed to facilitate their investigation and the implementation of lessons learnt.

Just Culture lies at the heart of an effective reporting system and such a system is needed in all aviation organisations to maintain and improve aviation safety.

This Declaration supports existing legislation, in particular Regulation (EU) No 376/2014 on the reporting, analysis and followup of occurrences in civil aviation, and is fully consistent with applicable rules.

Each organisation should, after consultation with their staff representatives, implement internal rules2 that are best suited to its internal and external specificities. These internal rules should be supported by documented processes and applied consistently through the organisation.

This Declaration constitutes a set of key principles that each organisation is encouraged to implement in the context of its Just Culture internal rules.

We, the signatories to this Declaration, will encourage our respective members to implement a Just Culture on the basis of the following key principles referred to in this Declaration.

The signatories agree to continue to work together to develop guidance and industry best practices material to assist Just Culture implementation by organisations in the various aviation sectors.

KEY PRINCIPLES OF A JUST CULTURE

1. Acting safely is a top priority.

2. Staff, at all levels, should be, as a starting point, considered to act in the interest of safety, in a manner commensurate with the training, experience and professional standards that fit their position or function. To achieve this organisations are responsible for providing their staff with the appropriate environment, tools, training and procedures.

3. It is acknowledged that, in an operational aviation industry environment, individuals, despite their training, expertise, experience, abilities and good will, may be faced with situations where the limits of human performance combined with unwanted and unpredictable systemic influences may lead to an undesirable outcome.

4. Analysis of reported occurrences by organisations should focus on system performance and contributing factors first and not on apportioning blame and/or focus on individual responsibilities, except in the cases foreseen under Regulation (EU) No 376/2014 and other applicable legislation.

5. When assessing individual responsibility, organisations should focus on determining if actions, omissions or decisions taken were commensurate with experience and training, and not on the outcome of an event.

6. Reporters of safety information, and any other person mentioned in the report, are protected from adverse consequences, in accordance with Regulation (EU) No 376/2014.

7. Whilst acknowledging that adverse events can frequently be the driver for analysis, positive behaviour and actions should be captured and encouraged.

8. Organisations should promote effective implementation of Just Culture principles within the organisation at all levels and with all parties, including their representatives. All should actively foster mutual trust and respect, and promote support and cooperation to build the necessary trust across the organisation. Staff should be educated in Just Culture principles and all relevant documentation should be made available.

9. Just Culture internal rules should include, amongst others, the definition of a process, including the actors involved, to determine an unacceptable behaviour, in accordance with its description in Regulation No 376/2014.

10. Just Culture internal rules should document how safety data is managed, stored, protected and disclosed. It should also document to what extent the organisation intends to share deidentified data for safety learning purposes.

11. Support provided by organisations, in cases where staff are subject to external procedures on the basis of an occurrence they have reported or been involved in, reinforces the mutual trust that is necessary to ensure an effective Just Culture.

12. A consistent and effective Just Culture environment requires going beyond publication of Just Culture internal rules.

13. To effectively implement a Just Culture staff at all levels, as well as top management, should understand and accept their responsibility with regards to Just Culture principles and internal rules and their promotion.

14. Organisations, in cooperation with involved parties, including their competent authority, should define how they intend to continuously promote and stimulate the implementation of Just Culture principles and practices throughout the organisation.

15. Organisations should regularly review and assess the maturity of their Just Culture internal rules and compare it to the Just Culture perception within the organisation. Benchmarking may also be of benefit and may be considered.

This nonlegally binding Declaration only considers Just Culture within the context of an organisation and does not address or overrule the judicial rules or proceedings applicable in individual Member States.

Article 16 (11) of Regulation (EU) No 376/2014 prescribes the presence of 'Just Culture internal rules', supported by internal processes that need to be adopted after consulting the organisation's staff representatives, and implemented in European aviation organisations.

On behalf of the European Business Aviation Association (EBAA)

Fabio GAMBA CEO

On behalf of Airports Council International (ACI EUROPE)

Gerard BOREL General Counsel

On behalf of the Association of European Airlines (AEA)

Athar Husain KHAN CEO

On behalf of the Airport Services

5. Samim AYDIN Chairman

On behalf of Aircraft Engineers International (ΑΕΙ) On behalf of the Airport Regions Conference (ARC)

Fred BRUGGEMAN Secretary General Léa BODOSSIAN Secretary General

On behalf of Air Traffic Controller's European Unions Coordination (ATCEUC)

Susana LLOREDA

On behalf of the Civil Air Navigation Services Organisation (CANSO)

Jeff POOLE Director General

On behalf of the European Transport Workers' Federation (ETF)

Γ Eduardo CHAGAS General Secretary l

On behalf of the Aerospace and Defence Industries Association of Europe (ASD)

Jan PIE Secretary General

On behalf of the European Cockpit Association (ECA)

Dirk POLLOCZEK President

On behalf of the European Regions Airline Association (ERA)

Simon MCNAMARA Director General

On behalf of the International Air Carrier Association (IACA)

Sylviane LUST Director General

On behalf of the International Federation of Aeronautical Information Management Associations (IFAIMA)

Fernando LOPES President of IFAIMA

On behalf of the International Federation of Air Traffic Controllers' Associations (IFATCA)

Patrik PETERS President & CEO

This Declaration was signed in Brussels, on Thursday 1st October

In the presence of ropean Commissioner for Transport

On behalf of the International Federation of Air Traffic Safety Electronics Associations (IFATSEA)

Theodore KYRITSIS Vice President

1

European Commission

presence of ropean Commissioner for


Conclusion ü  Just Culture is a mess ü Differential views ü  IFATCA will take a stand ü Differing MAs have differing experience

and maturity

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