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Just Culture critical in air traffic control

Ed Sims

Airways’ business is ensuring safe and efficient skies across the 30 million square kilometres of our airspace. It’s about maintaining a ‘no critical safety incident’ record sheet and retaining our leading rating in the Civil Air Navigation Services Organisation (CANSO) top quartile for safety performance. 

In the aviation industry mistakes can have dire consequences. That’s why we’re so focused on ensuring they don’t happen - and it’s why I am passionate about the safety of the people who work for Airways and the safety of people who fly in New Zealand’s airspace. 

With safety at the very heart of our business we have taken a strong lead in the implementation of Just Culture standards in New Zealand and I’m pleased to see that the local aviation industry is doing a great job of embedding the standards in their organisations. I’m particularly reassured to see a growing trend for the key safety assurance role in an aviation company to report directly to the CEO as this is critical to maintaining the highest level of safety for an organisation. 

We’ve adopted Just Culture standards in our air traffic control incident reporting process which means anyone who self-reports an unintended mistake isn’t subject to penalties. Our people are instead congratulated for reporting a concern and taking ownership of a mistake. 

Acknowledging the contribution of employees who make proactive reports, and ensuring there are no negative consequences for reporting unintentional mistakes, has had a huge impact on our reporting rates. It has built trust and engagement with staff, and helped us get to the root causes of incidents much faster. It is important, however, to maintain a clear distinction between deliberate or premeditated actions versus a simple mistake. A Just Culture doesn't mean a ‘no blame’ culture, and reckless or rogue behaviour is not tolerated in our safety-critical air traffic control industry.

There are four key principles for implementing and maintaining Just Culture successfully:

  1. Ownership – culture comes from the top of an organisation and CEOs must take proactive and visible ownership of Just Culture to ensure its success

  2. Trust – you must create a culture of trust where employees know they will be safe from any recrimination for voluntarily reporting incidents.  Staff perceptions will be driven by management behaviour and attitudes and how managers handle safety-related incidents

  3. Simplicity – businesses must ensure that the process of reporting events is accessible and simple for staff to follow and implement

  4. Clarity – there must be clearly defined Just Culture policies and processes which are discussed and agreed with your employees and the unions.  Airways has a Just Culture policy, statement and process which has been agreed with the unions and a specialist review panel to assess incidents or an individual to decide what remedial actions need to be taken. 

Just Culture standards can only be successfully adopted in organisations when actively owned, led and role-modelled by CEOs. I can’t stress this enough. For reporting to have a real effect on safety, being proactive and predictive is critical. A reactive, investigative culture will breed reluctance to report an incident, especially where an individual should report an incident, or their colleague’s mistake. 

Other barriers to the successful adoption of the Just Culture standards include rogue management selectively applying some principles, turning a blind eye to incidents, losing sight of the requirements and/or jumping to conclusions before reviewing all the facts. Historical patterns of behaviour that remain unchallenged for years can become ‘normal’ behaviour which defeats a Just Culture.    

There are many things we do at Airways to demonstrate that safety is our top priority. One is to start all board and executive team meetings with a safety review to ensure everyone is well-informed and our people get the clear message that the people at the top of the company are paying attention. I try to make sure too, that no one escapes the safety messages which are dotted all around our buildings and regularly pop up as screen saver reminders on computer screens.

An important lesson I have learnt too is that when communicating with staff about reporting it is right to express concern about the root causes that the prompted the reports, but you should never raise concerns about the number of reports. I made this mistake early on and was pulled up by staff who rightly said my comments could be interpreted as I wanted to see less reporting.  

Proactive incident reporting is like gold to a company like Airways because it enables us to flush out, learn from, and eliminate potential problems before they do any harm or there is an incident. In our business where maintaining safe skies critical, Just Culture is a must and not an optional extra.