In 2015, EU Regulation 376/2014 came into effect, requiring aviation organisations in the European Union to adopt and maintain a proactive, evidence-based Just Culture.The regulation aimed to encourage the open reporting of safety occurrences by eliminating the inappropriate punishment of front-line staff for genuine mistakes.
This was an essential step in ensuring safety across the industry. As air traffic continues to increase and the technical complexity of modern aircraft advances, it is becoming even more important to understand and recognise potential risks. Honest and open reporting of incidents is the first step in developing this understanding.
Experience shows us that accidents are often preceded by similar safety related risks and incidents – many of which go unreported. For example, eight days before the Taipei Chiang Kai-shek airport disaster in 2000, a pilot almost mistook runway 05R for take-off in poor visibility, despite the runway being closed for construction. This incident was not reported so no action was taken – and just days later, Flight 006 made the same mistake, this time with fatal results. The Just Culture regulation aims to prevent exactly this kind of incident. As Sean Parker from the UK Civil Aviation Authority (UK CAA) explains, “It’s important that employees report incidents for a number of reasons. Primarily so that employers understand when something has gone wrong and can learn from that incident and put in place measures to prevent it from happening again. They want to avoid it happening to someone else, potentially with more severe consequences”.
In the UK, Just Culture principles have always been central to the investigation of air safety occurrences and were applied by UK law through the Air Navigation Order until 2015 when EU Regulation 376/2014 replaced national laws in European Union related to occurrence reporting.This new legislation went much further than the previous legislation. It encompassed a broader range of organisations, some of which are not directly regulated by the Aviation Authorities, such as Ground Handling Organisations. It also introduced the requirement for aviation organisations to implement processes that guarantee the implementation of a Just Culture – a challenging move that was to bring real change.
The UK CAA contributed to the new EU regulation and recognises that transformation to a Just Culture cannot happen overnight. Everyone from front-line staff, line managers to senior management need to understand their Just Culture and internal reporting processes. Organisations should develop clear reporting processes, organisation-wide communication and provide all staff with effective training initiatives.
Organisations must ensure that their frontline staff won’t be punished as a result of reporting safety hazards or high-risk occurrences – and that staff believe this to be true. To deliver this, organisations need to overcome the behaviours that prevent occurrences being reported. Senior management needs to establish accessible tools to make it easier and ensure that employees receive adequate feedback to prove the value of the information they report.
Even more importantly, organisations need to ensure that the information is analysed and used effectively to identify potential hazards. Where required, appropriate corrective and preventive action must be taken to prevent accidents in the future. If this isn’t achieved, no benefit will be derived from the reporting process. Staff may even lose confidence in the system and stop reporting incidents altogether.
In the UK, open reporting and investigation has already helped many organisations appreciate and identify where potential risks lie and how to report them before incidents occur. The sooner the whole industry in the UK, EU and worldwide can adopt effective open and honest reporting systems, the more sophisticated safety information and risk detection will become.
Publications & Project
Risk Based Surveillance as a concept is gaining interest and momentum in the international aviation arena. Its principles are central to the new ICAO Annex 19 and are often the subject of safety conferences…
The relationship between the regulator and its regulated industry is always complex.