Just Culture Revisited – Guidance Material for Member Association

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Just Culture Revisited – Guidance Material for Member Association

53RD ANNUAL CONFERENCE, Gran Canaria, Spain, 5-9 May 2014

WP No. 163

Just Culture Revisited – Guidance Material for Member Association

Presented by SESAR/EASA Coordinator


Following a decade of advocating the need for just culture in aviation, and the establishment of the prosecutor expert training course, lessons learned by IFATCA from the various activities and initiatives that it has been involved in, has led to a recognition that there is a need for an evolution of Just Culture. This means the consideration of possible future policy and the development of guidance material and recommendations for IFATCA in this important enabler of aviation safety.


1.1 It took the aviation industry a decade to come to an acceptable definition of just culture, which would stand the test of time. The specific aim of just culture being bridging the gap between the needs for, and balancing, safety and the administration of justice. Of balancing the needs for safety with the need for accountability. At a global level the aviation side of the balance has published recommended practices (ICAO Annex 13 tenth Edition, 18.11.2010) and explanatory material which reflects the need for careful assessment of the interest of aviation safety and the administration of justice. At the European level European Union (EU) legislation has been passed defining just culture and starting to measure it as part of the EU Single European Sky (SES) performance scheme.

1.2 IFATCA defines just culture as:

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, wilful violations and destructive acts are not tolerated.”

Just Culture requires a corresponding national legal framework because the administration of justice is the responsibility of States. IFATCA shall encourage ICAO to foster the establishment accordingly in its Member States.

(IFATCA Professional and Technical Manual, Edition 2013 p. 4247)


1.3 The European Union Implementation Regulation in its performance regulation defines it as:

‘Just culture’ means 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. (EC 390/2013 OJ L 128/4, 9.5.2013)

1.4 The European Union proposed Implementation Regulation (EC COM 2012-776.EN.pdf) on amending the occurrence reporting in civil aviation (EU) No996/2010 and repealing directive No 2003/42/EC, (EC) No 1321/2007 and (EC) No 1330/2007 proposes the following recitals:

(31) A ‘Just Culture’ environment should encourage individuals to report safety related information. It should however not absolve individuals from their normal responsibilities. In this context, employees should not be punished on the basis of information they have provided in application of this Regulation, expect in case of gross negligence.

(32) It is important to clearly set the line which protects the reporter from prejudice or prosecution by providing a common understanding of the term gross negligence.

(33) Occurrences reported should be handled by designated persons working independently from other departments in order to contribute to the implementation of ‘Just Culture’ and enhance the confidence of individuals in the system.

And proposes the following definition in article 2.7:

‘Just Culture’ means 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.

And proposes the following articles on protection of the information sources in article 16:

1. Each organisation established in a Member State shall ensure that all personal data such as names or addresses of individual persons are only available to the persons referred to in Article 6(1). Disidentified information shall be disseminated within the organisation as appropriate. Each organisation established in a Member State shall processes personal data only to such an extent as necessary for the purpose of this Regulation and without prejudice to the national legislations implementing Directive 95/46/EC.

2. Each Member State shall ensure all personal data such as that names or addresses of individual persons are never recorded in the national database mentioned in Article 6(4). Disidentified information shall be made available to all relevant parties notably to allow them to discharge their obligations in terms of aviation safety improvement. Each Member State shall processes personal data only to such an extent as necessary for the purpose of this Regulation and without prejudice to the national legislations implementing Directive 95/46/EC.

3. Member States shall refrain from instituting proceedings in respect of unpremeditated or inadvertent infringements of the law which come to their attention only because they have been reported in application of Articles 4 and 5. This rule shall not apply in cases of gross negligence.

4. Employees who report incidents in accordance with Articles 4 and 5 shall not be subject to any prejudice by their employer on the basis of the information they have reported, except in cases of gross negligence.

5. Each organisation established in a Member State shall adopt internal rules describing how Just Culture principles, in particular the principle referred to in paragraph 4, are guaranteed and implemented within their organisation.

6. Each Member State shall establish a body responsible for the implementation of this Article. Employees can report to this body infringements to the rules established by this Article. Where appropriate, the designated body shall propose to its Member State the adoption of penalties as referred to in Article 21 towards the employer.

1.5 Is Just Culture only applicable to Europe? No. (Baumgartner M., Licu A., Van Dam R., Everything you always wanted to know about just culture(but were afraid to ask) , in Hindsight 18, Eurocontrol, December 2013) Just culture is not solely for application in Europe, is not intended as a solution to a uniquely European problem, and is intended for application and use globally. For a number of reasons, the just culture concept was picked up earlier in Europe, but that does not mean it is restricted to Europe alone. Europe, is a patchwork of sovereign states with sovereign judiciary powers that also has corporatised airlines and air navigation service providers. It has been a good breeding ground for JC. The EU has now enacted JC in its legal orders and regulations.

1.6 In ICAO the issue of the misuse of safety data and protecting safety reporting has been on the agenda for many years. It has become apparent that a key part of the successful implementation of JC relies upon a number of realistic deliverables that will stimulate a further understanding and an active and open coordination between the safety and judicial authorities.

1.7 Therefore, in the discussions and findings of the 36th Assembly, the AIG (Accident Investigation and Prevention) Divisional meeting in 2008 and the recommendations of the ICAO HLSC (High Level Safety conference) in March 2010 resulted in resolutions A37-2 and A37-3 of the 37th General Assembly on the sharing of safety information and the protection of safety data. Both resolutions, using the description of the JC initiative, instructed Council to strike a balance between the need for the protection of safety information and the need for the proper administration of justice. The Assembly furthermore noted the need to take into account the necessary interaction between safety and judicial authorities in the context of an open reporting culture. A special Safety Information Protection Task Force (SIPTF) was created as a result of these conclusions. In its final report, the SIPTF recommended a number of solutions, among which close cooperation between Safety and Justice and Just Culture figure prominently As a result, the new ICAO Annex 19 on Safety Management Systems now contains the definition of Just Culture that also is used by the EU.

1.8 The 38th ICAO Assembly of September/October 2013, amongst other actions, instructed the ICAO Council to take appropriate steps to ensuring and sustaining the availability of safety information required for the management, maintenance and improvement of safety. The Council is asked to propagate the necessary interaction between safety and judicial authorities in the context of open reporting culture, based on the findings and recommendations of the Safety Information Protection Task Force.

1.9 The EUROCONTROL Just Culture Task Force has members and observers from US, Australia and Asia and is represented in conferences and workshops globally. Finally: Just Culture has already conquered New York! When Captain Sullenberger was honoured by the City of New York after his epic ditching in the Hudson River, Mayor Bloomberg gave him a new copy of the book he had to leave in the cockpit. The title: Just Culture, of course! (Dekker S., Just Culture, Balancing Safety and Accountability, Alderscot 2007)

1.10 The International Confidential Aviation Safety Systems (ICASS) (http://asrs.arc.nasa.gov/international/overview.html#1) Group promotes confidential reporting systems as an effective method of enhancing flight safety in commercial air transport and general aviation operations.

The principal objectives of the ICASS Group are:

  • To provide advice and assistance in the start-up and operation of a confidential reporting system.
  • To facilitate the exchange of safety related information between independent confidential aviation reporting systems.
  • To identify solutions to common problems in the operation of such systems.

1.11 States participating to ICASS and sharing their experience are:

UNITED STATES – Aviation Safety Reporting System (ASRS) [1976]

UNITED KINGDOM – Confidential Human Incident Reporting Program (CHIRP) [1982]

CANADA – Confidential Aviation Safety Reporting Program [1985-95]- SECURITAS [1995-present]

AUSTRALIA – REPCON Confidential Reporting Scheme [1988]

RUSSIA – Voluntary Aviation Safety Reporting System (VASRP) [1992]

BRAZIL – Flight Safety Report System (RCSV) [1997]

JAPAN – Aviation Safety Information Network (ASI-NET) [1999]

FRANCE – Confidential Environment for Reporting (REC) [1999]

TAIWAN – Taiwan Aviation Confidential Safety Reporting System (TACARE) [2000]

KOREA – Korean Confidential Aviation Incident Reporting System (KAIRS) [2000]

CHINA – Sino Confidential Aviation Safety System (SCASS) [2004]

SINGAPORE – Singapore Confidential Aviation Incident Reporting (SINCAIR) [2004]

SPAIN – Safety Occurrence Reporting System (SNS) [2007] Including since 2013 (APRONS)

1.12 In 2008 the FAA and NATCA signed the Air Traffic Safety Action Program (ATSAP), which in the time between 2008 and 2012 (Flight Safety Foundation, Aerosafetyworld, August 2012) had more than 48,000 reports.

1.13 Initiatives such as the Just Culture Model Task Force (Eurocontrol 2012), the joint Eurocontrol/IFATCA (see Agenda item C10.2 Conference 2014) training on prosecutor expert courses, and the advanced arrangement (European Cockpit Association and IFATCA 2012) have been crucial to foster understanding of the Just Culture principles and contribute to bridging the gap between safety and the administration of justice.

Recent legal proceedings by prosecutors (Switzerland 2013) and court cases (Italy 2008, 10) have shown that the independence of administration of justice will be maintained, even if in certain cases it places elements such as responsibilities of ATCOs and duty of care above ICAO Convention. (Anastasi R., Profili di responsabilità penale nel controllo del traffic aereo, UniversItalia, Roma 2011 – ISBN 978-88-6507-203-5)

1.14 Thus the Just culture concept will continue to evolve and most probably will not disappear at the highest level. Progressive and forward thinking experts (Hollnagel E., Is justice really important? in Hindsight 18, Eurocontrol, December 2013) who have been developing resilience engineering and Safety II propose the following systemic view on just culture:

The need for judicial process to parallel safety investigations can be seen as a product of a particular view of safety (Safety-I) and of the search for causes that follows from that. This assumes that the hypothesis of different causes is right, and that people can make a moral judgment on whether what they did was right or wrong. But if the hypothesis of different causes is wrong and that instead people always try to do the best they can, then we cannot claim that it is reprehensible to do what they normally do in cases where the outcome is unsafe, unless we also claim that it is reprehensible in the cases where the outcome is acceptable. The logical consequence of that is that we should not allow people to do what they normally do, but instead oblige them to do what we think they should do (to work as we imagine work should be done). The consequences of that are unpalatable, to say the least.

There is probably not much hope of changing the common basis of justice today, which dates from the early sixth century codification of Roman law in Justinian’s Corpus Juris Civilis. Despite the attractiveness and advantages of a Safety-II perspective, we must realistically accept that it will co-exist with a Safety-I perspective for many years to come. But we can at least begin to be mindful about it, so that we do not do things out of habit but rather because they make sense vis-a-vis our purpose. While finding causes and holding people responsible may be reasonable for society and for the general sense of justice, it is of very limited practical value, if not directly counterproductive, for safety and safety management.

1.15 This paper argues the need for IFATCA to revisit the concept of just culture from its highest principle (the administration of justice versus civil aviation) to the level of its application at the company level (how organisations deal with JC). Trends in the application of JC, such as the need for ‘quick fixes’, the confusion between the use of JC in issues that have no relationship to safety, invoking the use of JC as a reason to act, including the use of punitive disciplinary action as a mechanism of bureaucratic accountability, have been common in the past within Air Navigation service Providers as well as at Airlines. This trend needs to be carefully monitored and this paper stipulates that there is a need for IFATCA to look at the latest developments and new emerging ideas in the area of JC. Furthermore this paper suggests that there is a need for guidance material that helps the Member Associations of IFATCA to prepare and to be ready in case the just culture concept at the company and ANSP level is not respected.

1.16 The inspiration form this paper came from a recent incident where a line manager drew the line and indicted a controller for failing to provide separation in high workload, CB situation in South Korea as well as our own experience in our everyday life as ATCOs.

1.17 This paper will explain the various influences of the operationalisation of just culture and show the consequences that put it at danger and where the challenges are for Aviation. It is important that the fundamental concept what a just culture can bring to safety needs to be understood, not only by the heads of Civil Aviation and the administration of justice, but first and foremost from the CEO of a Service provider through the organisational and line management chains down to the level of the supervisor and to the air traffic controller.


2.1 Looking back at nearly a decade of lobbying for a balance between safety and the administration of justice, one can say in retrospect that the process to achieve the level of understanding in Just Culture has been an incremental one, and that it has been influenced heavily by discussing semantics. In 1998 the so-called “Delta case” highlighted the need for a new approach between the administration of justice and aviation safety. Following the accidents of Ueberlingen and Milano Linate and the near mid-air collision in Japan, many institutions started to become active in what was perceived then, as the interference from the judicial authorities as “detrimental” to aviation safety. From a communication point of view, within aviation circles many began to preach to themselves (the convinced) about the need to better protect aviation safety data and those who make safety report and grant a “blame-free” or non-punishable work environment to Aviation safety professionals. Only in 2010, with the start of the working group on the just culture model policy, did the aviation community begin to talk in “understandable” terms and meaningful to the judicial world and recognise that the judicial perspective was not perverse but a way of reasoning that was in large part alien to many in the industry. In parallel were political initiatives, in particular in Europe under the umbrella of the Single European Sky (SES), which identified and adopted some of the ideas and started to incorporate these into the legal framework. This led to the beginnings of a change in the understanding that the various professionals involved and associated with adjudging the balance of safety and the administration of justice.

Note: On 10 December 1998, an incident occurred at Schiphol (Amsterdam) Airport in which a Delta Air Lines Boeing 767 aborted its take-off roll when the pilots observed a towed Boeing 747 crossing the runway in front of them. At the time of the incident, low visibility procedures were in force. After unclear radio transmissions with the tow truck driver, an assistant controller had passed her interpretation of the tow’s position to the trainee controller responsible for the runway. The assistant controller did not have a screen that could show ground-radar pictures. The trainee controller did, and took the position of the tow at the edge of the runway to mean that the crossing had been completed. Buttons on a newly-added panel in the tower for controlling lighted stop-bars at runway intersections proved ambiguous, but at the time all looked in order, and he cleared the other jet for take-off. Meanwhile, the coach of the trainee controller was performing supervisor duties in the tower. (Skybrary 2014) 

2.2 Semantics and their use have not helped the cause of Just Culture directly. Indirectly they have been a necessary step that has permitted an appreciation of the nuances of the balance of safety and justice and thus added to the industry and wider communities’ knowledge.

2.3 The message that the aviation community conveyed was that safety had a priority over the system of justice. The use of language such as blame-free and nonpunitive – which both linguistically and in their practical application generated their own semantic arguments – only served to reinforce this impression (Schubert F., Legal Barriers to safety Culture in Aviation (2004) XX Annals of Air & Space Law 19, 56). When reaching out to the administration of justice and discussing the notion of what is the real intention of just culture, it became clear that there was a need to find a balance that reconciled the needs of safety and of justice.

2.4 Instead of continuing to impress for the need for special treatment, and following the Milano and Ueberlingen accidents, Eurocontrol created with a mandate from ECAC (European Civil Aviation Conference) an Action Group on Aviation Safety (AGAS) and just culture was explicitly included as being part of a possible solution. Furthermore, in Switzerland the whole aviation sector was reorganised (NLR , various authors, Aviation safety management in Switzerland, Recovering from the myth of perfection, 2003, NLR –CR 2003-316) and just culture was mentioned as one of the fundamental enablers to achieve an increase in aviation safety. Other serious incidents and accidents created a need, as a result, and highlighted the need for an approach to address the judicial influence on the willingness of aviation professionals to report and address the potential for denying the aviation industry the raw material essential for safety interventions that can make the aviation system safer.

2.5 Additionally, The Netherlands adapted its national legal framework to the mandatory occurrence reporting scheme directive (2003/42) which increased the need for debate at the institutional level and the testing of the new arrangements in the context of the balance between justice and aviation safety: Bijlsma in hindsight described it this way:

The aviation world is, by nature, international, dynamic and very sensitive to safety. The world of the prosecutor and the courts is, by nature, national, resistant to progressive change and very sensitive to the rule of law. These are two distinct worlds that seldom meet. Between these two worlds there is the world of Just Culture Task Force

(Bijlsma F., Justice and Safety, in Hindsight 18, Eurocontrol, December 2013).

2.6 The changes in recent EU legislation have brought yet another interesting development in the decade long discussions and has now reached a new level where just culture was defined in the first EU legislation on performance scheme 690/2010 (2k). The latest legislation on performance (EC 390/2013) proposes to measure just culture implementation at the national/local level. This is as part of the performance measurement monitoring indicators on safety. This brings yet another layer of complexity and confusion in an already complicated topic.

2.7 The term gross negligence, which is fundamental to the conception of JC, is used in all definitions of JC and introduces a ‘judgment’ into the equation that JC seeks to balance. The notion behind this is that we can draw the line between what is acceptable and what is gross negligence. Eurocontrol and Sidney Dekker have called this the line between acceptable and unacceptable behaviour. How to draw this line, or who is going to draw this line, has become crucial and defining factor in the application of JC in an ANSP. In IFATCA’s experience this is highly problematic. In both the just culture Task Force and the Model policy it has been agreed that the line can only be drawn by the administration of justice. However, Civil Aviation Authorities and/or Air Navigation Service Providers and/or Airlines are also required at the moment to draw the line, and then determine the consequences of having done so by various means and measures and these are in the majority of cases where gross negligence is determined. This practical application of JC at the ANSP level is one beset with confusion, contradiction, with imaginative and inappropriate interpretations of what JC is (or is not) and how it should be applied as well as the blurring of bureaucratic or managerial responsibility and accountability to act and hold individuals to account – for matters that are not related to the basic principle of balancing safety and accountability. The question revolves around the issue of what is negligent, what is reckless and what is punishable.

2.8 Recent examples e.g. South Korea, have shown the need to provide further guidance to the IFATCA Member Associations on this difficult topic. To the best of the knowledge of the authors, with the exception of the Japan Airlines, case no controller has been found guilty for a near miss by a judge. Though being aware that any investigation or prosecution for an incident can have a very disruptive impact on the life of the concerned ATCO, the operational team and a whole unit, it is rather the exception than the rule, that for near misses Air traffic controllers are being prosecuted. It is however, much more common that an Air traffic controller gets, after an near miss, suspended, disciplined and put into re-training by its Civil Aviation authority and/or Air Navigation Service Provider.

2.9 It is proposed that the guidance material could be elaborated which includes an approach to utilizing and working in two-dimensions to operationalize the just culture riddle. In this paper we propose to look at the National/international level and the ANSP level.

2.10 But the guidance alone is insufficient. The experience of IFATCA, having worked with JC in practise, leads to the view that the widely held belief within the industry that the trajectory of JC is complete and that the enabling mechanisms that serve the objectives of JC are in place is far from being so. That more needs to be done to advance the JC concept to improve its salience and applicability as well as to take a progressive perspective for the next steps for JC so that it is sustained.

Navigating the process pathways of JC

3.1 By Establishing, at the national/international level, what happens after an incident in the ATM environment it is possible to determine the influences on JC as well potential consequences. An exemplar of a flow chart is displayed below. There are of course local differences and the national/international action is also dependant on the category of the incident/accident.

Fig. 1 a possible flow chart after an incident

3.2 When an incident occurs each ANSP and/or state has a different process or approach to deal with it. For the matters that this paper considers, there are basically three layers to process or approach:

a) One is the Air navigation service providers’ reaction to the incident. This can be in various forms.

b) If it is an incident where the Accident investigation is required there will be a layer, which is normally independent of the ANSP and will be carried out by the Aviation Accident Investigation Body (AIB). This is the case according to the various international legal instruments a requirement.

c) There is the possibility that in a serious incident, which is being reported to the administration of justice a file, is being opened at the administration of justice level.

All these investigation can be carried out at the same time, or in differed timing. This figure shows a possibility, which can be different in any country. It is however important that the member association is able to draw up such a flow chart, in the case to be better prepared in a case an incident happens.

3.3 Focussing solely on the ANSP level, a member association might identify the various possibilities of the pathway of post incident processes. As an example of possible actions within an ANSP 3 possibilities are represented in the figure 2 below:

3.4 Just culture is described above at bridging the gap between the world of the judiciary and aviation, one can easily imagine that it will have to be applied throughout the full organisational and institutional chain, in particular starting at the ANSP or even the ATC Unit level, going up to the CEO level and then to the Civil Aviation authority. This level is where there is immediate interaction between people with authority (managers with authority to implement extra training, disciplinary actions, etc.) and the individuals involved after an incident/accident. Therefore this level can be particularly fragile and needs extra attention.

3.5 Focussing on the ANSP level we think there is a need for IFATCA to develop guidance material for MAs, and this should include covering the following issues:

3.6 Influences on JC during post-incident processes and attendant consequences

3.6.1 It is common that managers hold the opinion, the belief, that it is they who can decide, or they who have the bureaucratic accountability to decide, whether an ATCO acted negligently or gross negligence or not. This is an issue that has been discussed for a long time within the aviation world, and many different solutions have been suggested. The way that managers interpret the situations presented to them and they subsequently act can have significant consequences on the durability of JC and thus the willingness to report openly. Seeing the controller as a broken system component is one consequence of this approach to applying JC, and can have far reaching consequences.

3.6.2 One approach to an assessment, by those who are involved in the determination of whether an event is normal work or gross negligence is to consider what other controllers would have done in a similar situation. The consequence of not doing so is to make arbitrary decisions that can substantially undermine the essence of JC.

3.6.3 In any untoward event, it is commonplace for the influence of the individual ATCO to be overrated. Research reveals that if you change the individual, you are likely to have roughly the same outcomes in 95% of cases (W. Edwards Deming, Out of the Crisis, 1982). What this means is that variation due to individuals (not humans, but rather the specific person) compared to the variation due to the design of the system’ (goals, work design and flow, procedures, equipment, training, incentives, punishments, etc.) is insignificant. The consequences of taking this approach are manifold. Most significant perhaps is that if the intention is to make the system safer, all that happens is that the nature of the system behaviour that contributes to unexpected system behaviours is obscured and inappropriate safety interventions are made. In extremis, this approach leads to making the system unstable and potentially degrades safety. Disciplinary action is often a result of a determination of negligence or gross negligence. However this can be seen to be unfair and arbitrary if we consider the point that Erik Hollnagel makes below:

If the hypothesis of different causes is wrong and that instead people always try to do the best they can, then we cannot claim that it is reprehensible to do what they normally do in cases where the outcome is unsafe, unless we also claim that it is reprehensible in the cases where the outcome is acceptable. The logical consequence of that is that we should not allow people to do what they normally do, but instead oblige them to do what we think they should do (to work as we imagine work should be done). The consequences of that are unpalatable, to say the least.

3.7 Incident and unhindered reporting is what JC strives to bolster – to learn how the system is functioning when things do not go as expected. What will happen to other people’s willingness to report safety information, and thereby the organizational opportunities to learn from incidents, if the operational community feel punished or getting into trouble because they are adjudged in an arbitrary or incomplete way? Remember it is the reporting community that decides whether they have been treated fairly or not.

3.8 An influence upon JC that can be a measure of how progressive an ANSP is, involves the process itself, how an individual controller or engineer are treated once an untoward event has occurred. Does the current process stigmatise those involved or is it supportive and reinforces the value of learning from these events? However this reflects the organizations perspective of how the reporter is treated: as an individual who gets blamed for getting into trouble or treated as empowered employees, who can contribute meaningfully to organizational safety (Dekker, S.W.A, Laursen, T., From punitive action to confidential reporting. Patient Safety and Healthcare, www.psqh.com, 2007). The use of language in any reports or narratives of accounts of what happened is an important feature of JC. Judgemental language can have as a consequence the evolution of beliefs that the process is unfair and thus can negatively impact JC. Furthermore, the issue also concerns how ATCOs react amongst themselves. How controllers will deal with the situation when a team-member involved in an incident/accident is a parameter for how well your organization and individuals within it handle just culture?

3.9 The final influence on JC to consider in this paper is how does an ANSP consider or value the human being. Does it consider the engineer or controller as an errant actor or does its philosophy consider that the humans are all part of a system interconnected to each other that makes the system function. ATM is a team of people who work together to make ATC safe and efficient. It is about ATCOs, Managers, Technicians, Supervisors, Assistants, Pilots, Airways, Technology, Structure, etc. that together create a safe system. Targeting individuals within the system can have consequences on many levels, but especially it will impact the willingness to share and learn from safety information.

3.10 Experience shows that those organizations that have embarked on such a change of culture had to learn the hard way and it is a lengthy path. In many cases it is difficult to adapt to a different approach to what has been done in the past. At the same time any ANSP which is willing to embark will have the advantage to put safety at the forefront of the discussions for many years and will avoid that an ANSP will be forced to reorganize itself after an accident or serious incident following outside pressure (press, society, government). This path of changing the way incidents or accidents are being looked at will have to go on with a structural adaptation of the ANSP. Therefore no ANSP, nor any of the Member Association where this change of approach has been chosen, has achieved this on its own. It is important that assistance is given and that all the stakeholders involved in the process of producing safety are associated to the discussions and the culture change. Along the path it has been observed, that a backslash can be experienced, however it has been judged worth the journey by that organization which has accepted to go this way.

What potential Guidance Material might include

Here are some ideas for issues that can be part of the new guidance material:

4.1 Critical Incident Stress Management (see IFATCA manual 4228)

First and foremost it is important to care about the controller and/or the controllers involved. IFATCA recommends having Critical Incident Stress Management system in place in order to assist with a peer based scheme the psychological well being of the controller(s) involved in an incident. This will assist in the longer term to keep the controller part of the professional group thus not being stigmatized and permitting a quick re-introduction into the operational environment.

4.2 Professional and possible legal assistance by the association (see IFATCA Manual 4247 ff)

Second the ATCO will need support of various degrees, in particular if disciplinary or legal actions are being taken. In any case the ATCO will have to be supported by the association in form of education (explaining what is happening), giving expertise (assist in the interview with the Accident Investigation Body) and assist in the defence if the ANSP tries to discipline the ATCO for the incident and or if at a later stage a legal procedure is being put in place. This might also need the support of the association lawyer.

4.3 Learning culture – improves safety

The association can and should play an important role to improve safety and the economics of the ANSP as a system. This is a long and uphill journey. First of all, the association will have to introduce the notion of safety II (Eurocontrol, From Safety I to Safety-II: A White Paper, September 2013). Explain to the ANSP that the real contribution to safety and the richness of the experience at the sharp end (meaning at the sector) is extremely valuable and that it is important from a systemic point of view to use the gained information from incidents/accidents to learn for the next time.

4.4 The cost of disciplinary actions

It is as well important to identify the economic impact of a suspended air traffic controller for the ANSP. By punishing an ATCO without addressing the systemic elements, a potentially detrimental signal is send out to the ATCO community. Such as suspension or disciplinary actions will introduce a fear from reporting and thus reduce the source of information of daily work. This could lead to preventing learning from incidents and increases the risk that incidents will happen again. Furthermore it will potentially damage trust amongst stakeholders. This creates always the potential for another incident and/or an accident to happen which economically speaking will be much more expensive than any change in safety culture.

4.5 Help the managers to understand that the ATCO can help the whole organization, especially the other ATCOs, where there is increased risk for getting into trouble and thereby how the organization can protect itself in the future. What makes systems unsafe is making individuals feel punished and the illusion that systems are inherently safe.

4.6 It can help to look at the individual who was involved in the incident as a source of information for where the organization is at risk, much more than looking at the individual as a source of risk. This is an important balance that can be used to find out whether your organization is good at balancing ANSP internal safety and justice.

4.7 The amount of money and resources spend in a disciplinary or legal action against an ATCO might be much higher than investing in the systemic causes for an incident and try to learn from it for the benefit for the overall system.

4.8 Become the safety champion

Further the association could propose based on this incident to embark on a different approach with regard to safety – or safety culture changes, involving all the actors in the Civil Air Traffic Management. This could ideally start with mapping out the various actors and organize a workshop or a conference to address the Safety Management System recommendations from ICAO and the Annex 19 preparatory work.

4.9 Guidance on how the systems approach influences just culture given that this approach does not differentiate the role of the human as being a component. This approach promotes the role of the human as an integral part of the system, whose activity cannot be divorced from the system as a whole. So if your organization decides to perform any form of disciplinary actions, retraining or demotion, it should be the whole system rather than the individual.


5.1 The evolution of JC has led to plenty of information and publications around the notion of Just culture. Some of the elements have been, or are becoming law in certain parts of the world. It is expected that the notion of Just Culture will have to evolve to include elements closer to the sharp end and the application of JC in practise. This has been and continues to be lacking (by this it is meant, Air navigation service providers, ATC units, the air traffic controller and engineering teams and those who have both a legitimate or indirect influence on the salience and delicate nature JC). This move towards just culture at all levels poses new challenges and therefore it is concluded in this paper that IFATCA develops and establishes further guidance material on the notion of just culture (or learning culture) that directly addresses the known limitations of the way that JC has been enacted.

5.2 Such guidance material could include methods to identify the legal framework and the level of understanding of just culture at the national, corporate and unit level. Training guidelines and assistance could be provided to member associations of IFATCA in order to be prepared for the next incident (and the aftermath of it).

5.3 But this training must extend to those who are in managerial and supervisory positions and who are arbitrating JC in practise. JC is fragile, it is brittle, and what has taken time to make purposeful and led to trust and the belief that is fair, can swiftly become lost, and even more difficult to recover.

5.4 Finally, the belief by some or many in industry that JC needs no further development needs to be challenged in an informed and considered way. IFATCA needs to undertake the work to develop this facet of the evolution of JC in an intelligent way so that it can begin to argue with authority.


6.1 The Executive Board tasks the Global Safety Team to review the manual (chapters 11.2 ff) and provide advice on the possibility to add guidance material to the Technical and professional manual and include a detailed analysis of the influences on sustaining JC and mitigating any consequences of these influences.

6.2 The Executive board tasks the Global safety Team to undertake the development of an IFATCA position on the future of JC and the options available, as well as the utility of the current conception of JC against the changes that progressive safety science brings.

Last Update: October 1, 2020  

May 31, 2020   284   Jean-Francois Lepage    2014    

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