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The Just Culture Initiative

Roderick D. van DamHead of Legal Service, EUROCONTROL

ICAO / ASPA Regional Seminar10-11 April 2007

European Organisation for the Safety of Air Navigation

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Outline

Setting the (European) scene

Concept of Just Culture

Challenges

Way forward – European and International approaches

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24 Hours of Europe Air Traffic: September 10, 2004

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Eurocontrol (37 +European Community)

ECAC (42)EU (27)

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Membership of the EU, EUROCONTROL and

ECAC

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CG

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EUROCONTROL

European Organisation for the Safety of Air Navigation

EUROCONTROL Convention• 13 December 1960

Amended Convention• Protocol 12 February 1981

Revised Convention • Protocol of 27 June 1997

Not yet in force – however, early implementation of certain provisions of the revised Convention

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Management of pan-European programmes

Research & Development work aimed at increasing Air Traffic Control capacity and safety in Europe

Operation of a Central Flow Management Unit

Collection of Route Charges on behalf of Member States and through bilateral agreements with non-Member States

Provision of Air Traffic Services• Management of an international (4 States) ATC Centre: Maastricht• Development of an international (8 States) ATC Centre: CEATS

EUROCONTROL - CORE BUSINESS

Provision of training, education and knowledge transfer in Air Navigation Services inside and outside Europe

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Setting the scene

Accidents in 2001 & 2002Strengthen the need for continuous safety improvementsLed to, inter alia, creation of Safety Data Reporting and Data Flow Task Force (SAFREP)

SAFREP Report on ATM incident reporting culture: Impediments and PracticesInvolving EUROCONTROL, European Commission, IFATCA, IATA, States and ANSPs representatives Conclusions and Recommendations

EUROCONTROL to continue to actively support and cooperate with ICAO

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Setting the scene

European Safety Programme for ATM (ESP)Supporting 42 ECAC StatesSafety maturity to a minimum common level by December 2008

High Priority Area: Incident Reporting and Data Sharing

Special emphasis on “Just Culture”

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ATM Safety Maturity in Europe

Maturity (%)

50

55

60

65

70

75

80

2002 2003 2004 2005 2006

ANSPs

Regulator

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Concept of Just Culture

What is “Just Culture”?

EUROCONTROL / SAFREP definition:

“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, wilful violations and destructive acts are not tolerated”

Definition to be submitted to next ICAO Assembly

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Concept of Just Culture

Main elements:

Gross negligence, willful violations and destructive acts

Actions, omissions and decisions expected from someone with your level of training and experience

Not tolerated

Not punished

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Concept of Just Culture

Objectives:To provide increase in reportingNot to justify absence of reporting

Evolved from punitive-free reporting, blame free reporting

To achieve a balance between interests of safety (and protection of safety information) while allowing proper administration of justice

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Concept of Just Culture

Involving a number of players:States (Regulators, prosecutors, etc.)ANSPs“Reporters” (e.g. controllers)International / regional organisations

A number of challenges must be addressed to establish “Just Culture”

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Challenges

Powers of judicial authorities vs. Protection of safety information

Both addressed by ICAO Annex 13:

Section 4.2 : Non – Disclosure of records

Legal Guidance: (new) Annex E » Not purpose of protecting safety information to

interfere with proper administration of justice» Protection of qualified safety information under

conditions is part of a State’s responsibilities

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Challenges

Powers of judicial authorities vs. Protection of safety information

Relevant Assembly Resolutions:

A31-10: “Urges Contracting States (…) to implement voluntary and non punitive reporting systems”

A33-17: “Instructs the Sec. Gen. to develop appropriate guidance material related to laws and regulations to protect certain accident and incident records”A35-17: “Instructs the Council to develop appropriate legal guidance that will assists States (…) to protect information gathered from all relevant safety data collection and processing systems,while allowing for the proper administration of justice in the State”

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Challenges

• European Level – same “conflict”

• Directive 94/56/EC on the investigation of civil aviation accidents and incidents

• Directive 2003/42/EC on occurrence reporting in civil aviation

• EUROCONTROL• ESARR 2 and Guidance Material

•States shall refrain from initiating proceedings (except in case of gross negligence)

•No prejudice from employer

•Without prejudice to applicable rules:- penal law- related to access to information by judicial authorities

Directivescurrently

under review

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Challenges

Cooperation betweenJustice and ATM/Safety experts

Public interest Safeguards

Respect roles and responsibilitiesAddress grey areas

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Challenges

Communication and trustTrust at all level (ANSPs)

Staff / ManagersBetween ManagersImportant role of management

TrainingReporting is an obligation – part of professional duty

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Challenges

Liability of ATCLack of harmonization

National frameworks

Administrative sanctions

Criminal liability

Disciplinary sanctions

CivilLiability

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Challenges

Trend in Europe: ATC and criminal proceedings

Relatively recent trendFurther to an accident:

Linate caseÜberlingen caseMt-St-Odile case

Further to an incident:Delta case

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Challenges

Increase of criminal proceedings - Why?Basic principles have not changedIncrease awareness of safety mattersNot solely affecting aviation

Impact on reporting“Vicious circle”Calls for Just Culture

Less reporting More incidents/accidents

Increase in legal proceedings

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Way Forward

Potential Impact on ATM safety recognised:

Incidents report are essential to ATM safetyNeed to ensure flow of informationNeed to provide environment supporting reporting (and address “fear” of reporting)

Just Culture concept –supporting safety reporting in a culture that is “just” to all concerned

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Way Forward

To achieve this…

Review and implement applicable legislative framework, structures and procedures

National levelInternational level

However – focus not only on legal framework:Dialogue Justice / SafetyTrust and CommunicationTraining

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Way Forward

Aim for balanceRespecting roles and responsibilities of each party

Seek collaborative approach of all concerned

Use best practices and experiences

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Endorse and further develop Just Culture at international level Next ICAO Assembly