The Human Factors Analysis and Classification System—HFACS
1. Unsafe Acts
for Unsafe Acts
3. Unsafe Supervision
HFACS and Wildland Fatality Investigations
Hugh Carson wrote this
article a few days after the Cramer Fire
Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report
A Roadmap to a Just Culture:
Enhancing the Safety Environment
Forward by James Reason
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form
Rainbow Springs Fire, 1984 — Incident Commander Narration
Tools to Identify Lessons Learned
An FAA website presents 3
tools to identify lessons learned from accidents. The site also
includes an animated
illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."
A Roadmap to a Just Culture:
Enhancing the Safety Environment
Prepared by: GAIN Working Group E,
Flight Ops/ATC Ops Safety Information Sharing
First Edition • September 2004
3. Creating a Just Culture
3.1 Benefits of a Just Culture
The benefits that
can be gained from the creation of a Just Culture in an organization
include measurable effects such as increased event reports and corrective
taken, as well as intangible organizational and managerial benefits:
- A Just Culture can lead to not only increased event reporting, particularly
of previously unreported events, but also the identification of trends
that will provide opportunities to address latent safety problems.
- It has
been estimated that for each major accident involving fatalities, there
are as many as several hundred unreported incidents that, properly investigated,
might have identified an underlying problem in time to prevent the
(GAIN Operator’s Flight Safety Handbook, 1999)
- A lack of reported
events is not indicative of a safe operation, and likewise, an increase
in reported events is not indicative of a decrease in safety. Event reporting
illuminates potential safety concerns, and any increase in such reporting
should be seen as a healthy safety indicator.
- Peter Majgard Nørbjerg
of Naviair, Denmark’s air traffic service provider, reported that after
a June 2001 change to Denmark’s law making confidential and non-punitive
reporting possible for aviation professionals, the number of reports
in Danish air traffic control rose from approximately 15 per year to more
than 900 in
the first year alone.
- The process of clearly establishing acceptable versus unacceptable
behavior, if done properly in a collaborative environment, brings together
different members of an organization that often have infrequent contact
in policy decision-making. This contact, as well as the resulting common
understanding of where the lines are drawn for punitive actions, enhances
the trust that
is at the core of developing Just Culture.
- Patrick Hudson noted in
2001 that “most violations are caused by a desire to please rather than
willfulness.” This observation emphasizes the inherent nature of the
majority of safety violations: (i) that they are indeed inadvertent and (ii)
that they are intended to further the organization’s operational objectives.
This fact is well known on the “front lines” of an airline or
air traffic service provider, but is often obscured further up in the management
structure, particularly during an investigation of a violation or accident.
Likewise, front-line workers may not have a clear understanding of which procedures
are “red light” rules (never to be broken) and which are “yellow
light” rules (expected to be broken, but will be punished if an
accident occurs). Establishing a well-defined, well-monitored Just Culture
help all members of an organization to better define their own responsibilities
and understand the roles, influences, and motivations of others in
- It can be expected that a Just Culture will increase confidence of
front-line employees in its management’s prioritization of safety over
its interest in assigning blame. It will reinforce the organization’s
common vision and values regarding the need to put safety first in all aspects
of its operation.
More Effective Safety and Operational Management
- It can be expected that a Just Culture will enhance the organization’s
effectiveness by defining job performance expectations, establishing clear
guidelines for the consequences of deviance from procedures, and promoting
the continuous review of policies and procedures.
- Just Culture can
allow an organization to be better able to determine whether violations
are occurring infrequently or if deviation from established procedures has
normalized among its front-line employees and supervisors.
or ineffective management structures can be manifested in many ways,
as by operational inefficiencies, lost opportunities, or safety lapses.
Culture is primarily implemented by a safety motive, it is recognized “that
the same factors which are creating accidents are creating production losses
as well as quality and cost problems.” (Capt. Bertrand DeCourville,
Air France, 1999)
3.2 What is expected to change in an organization with a
The shift from the traditional “Blame Culture” to
a more constructive “Just Culture” can be expected to have tangible
benefits that will contribute positively to the overall safety culture of
an organization by emphasizing two crucial, yet not mutually-exclusive, concepts:
- Human error is inevitable and the system needs to be continually
monitored and improved to accommodate those errors.
are accountable for their actions if they knowingly violate safety
procedures or policies.
A Just Culture is necessary for an organization to effectively
monitor the safety of its system both by understanding the effects of
normal human error on the system and by demonstrating its resolve to enforce
operator responsibility. This responsibility includes adherence to safety
regulations as well as reporting inadvertent errors that can alert an
organization to latent safety dangers. Operating with a Just Culture will
conducive to reporting and collaborative decision-making regarding policy
and procedural changes.
One example of the marked changes in an organization as a result of creation
of Just Culture occurred at Naviair, the air traffic service provider in Denmark,
made possible through a change in its national law. (Details are described
in section 4.1)
Based on the experience of Naviair and others who have implemented Just Culture,
the following values can be expected to be prevalent throughout the organization:
- People at all levels understand the hazards and risk inherent in
their operations and those with whom they interface.
- Personnel continuously
work to identify and control or manage hazards or potential hazards.
are understood, efforts are made to eliminate potential errors from
the system, and willful violations are not tolerated.
- Employees and management
understand and agree on what is acceptable and unacceptable.
are encouraged to report safety hazards.
- When hazards are reported,
they are analyzed using a hazard-based methodology, and appropriate
action is taken.
- Hazards, and actions to control them, are tracked and reported
at all levels of the organization.
- Employees are encouraged to develop
and apply their own skills and knowledge to enhance organizational
and management communicate openly and frequently concerning safety
reports are presented to staff so that everyone learns the lessons.
is provided to users and the aviation community:
- Acknowledgement – reporters like to know whether their report was
received and what will happen to it, what to expect and when.
- Feedback – it
is important that the users see the benefits of their reporting
in knowledge sharing. If not, the system will die out.
3.3 Creating and implementing a Just Culture
This section briefly describes
some of the main steps as well as potential obstacles to achieving a
Just Culture. These have come from a number of sources: including Reason (1997);
Johnson (2003); lessons from the Danish experience; EUROCONTROL ESARR2
in 2000 and Vecchio-Sadus and Griffiths (2004).
1. Legal Aspects
In order to reduce the legal impediments to reporting, the
two most important issues are: i) indemnity against disciplinary proceedings
and ii) having a legal framework that supports reporting of incidents.
The first steps in changing the legal aspects could be to:
- Substantiate the current legal situation; does it need to be changed?
possibilities of change with company lawyers / legal advisors.
with operational personnel what changes in the legal policy they
think would improve incident reporting.
|Potential Obstacles: For many organizations, the main challenge of developing
a Just Culture will be to change the legislation, especially if the changes
are counter to societal legislation.
2. Reporting Policy and Procedures
It is important that the following issues
are considered with regard to the underlying reporting structure and
- Confidentiality or de-identification of reports.
of agency/department collecting and analyzing the reports from those
bodies with the authority to institute disciplinary proceedings and impose
commitment to safety.
- Some degree of independence must be granted
to the managers of the reporting system.
|Potential Obstacles: Persuading
senior management of the need for creating a Just Culture and to
resources to it may be difficult. For many organizations, the main challenge
of developing a Just Culture will be to change the legislation, especially
if the changes
are counter to societal legislation.
3. Methods of Reporting
It is important that issues such as the following
are considered with regard to the method by which reports will be collected:
- Rapid, useful, accessible and intelligible feedback to the reporting
- Ease of making the report - voluntary reporting should not
be perceived as an extra task
- Clear and unambiguous directions for
reporting and accessibility to reporting means
- Professional handling
of investigation and lesson dissemination
The first steps to develop
Culture’ Reporting System could be:
- Decide on voluntary versus
mandatory reporting system
- Decide on anonymous, confidential, open
- Develop procedures for determining culpability (such
as the Just Culture decision tree) and follow-up action (type of
discipline or coaching)
- Decide who shall decide culpability (e.g., team consists
of safety; operations; management; HR)
- Draft a plan and discuss with
a small selection of operational personnel
if and how the reports will be further investigated (the focus
of the investigation; face-to-face interview.)
- Decide which reports will be further investigated
(those which are most severe; or those with the most learning potential).
who will investigate the reports.
|Potential Obstacles: It may not be obvious to all organizations
which system would suit them best. Ideally, a variety of reporting
methods (or a flexible
method) will be implemented, as not one reporting method will suit
everyone’s needs. It may be necessary for the organization to
survey the needs of the potential users to better understand which
reporting method would be more readily accepted. A system that is unclear
ambiguous could create distrust in the system, so it is necessary
that the procedures to decide culpability must be clear and understood
all. Reporters may not reveal their identity (e.g. in a confidential
reporting system) or choose not to be interviewed, which could prevent
any further investigation of an event.
4. Determine Roles and Responsibilities, Tasks and Timescale
For such a system
to thrive, a number of different people need to be involved in the implementation
and maintenance of the system. A ‘local champion’ will be needed
to promote and act as guarantor to ensure the assurances of anonymity will
be preserved in the face of external or managerial pressures. Decide and select
- Champion the system • Educate users and implement system
and analyze the reports
- Decide which department will be involved in
the disciplinary (decision making) process
- Feedback the information
- Develop and maintain the data collection
|Potential Obstacles: Having sufficient resources (e.g.
people) to run the system, as well as having enough of the ‘right’ kind-of
people, who are energetic, well-liked, well-known and respected in the
company. Maintaining the energy required for the system to function.
5. Develop Reporting Form
It is important to have a reporting form that encourages
accurate and complete reporting (e.g. questions that are understandable);
otherwise reporters may provide erroneous or misleading responses. Determine:
- What information you
want to collect (e.g. only that information that will improve learning
in the organization).
- What you want to do with the information (e.g.
case studies; summary data) as this will determine what information
format you want to collect it in (e.g. electronic, paper or both).
resources are required to develop the system (people, costs).
(and how) the reporting form should be integrated with the current
incident reporting system.
|Potential Obstacles: It could be possible
that too much
/irrelevant data is collected. It is important that it is kept
simple, but with enough detail that useful analysis can be applied
6. Develop Template for Feedback to Potential Users
- What type of information you want to disseminate (e.g. summary; case
studies; “hotspots”; human factors data) • How to disseminate
the information (e.g. newsletter)
- Who will be involved (writing; editing
newsletter; senior management endorsing action plan) • How often you
will disseminate the feedback
- Template style of the newsletter,
|Potential Obstacles: The newsletter is not read. It
may be necessary to find out what sort of information the audience would like to know
about; provide examples that will be of interest and relevant to
their job. One may need to vary the style over time, so that it maintains
their attention, and so that they are likely to contribute to it.
7. Develop a Plan for Educating the Users and Implementing the System
reporters must know about the reporting scheme and know how to submit
a report; this will include induction courses; periodic retraining to remind
the importance of reporting; and ensuring that staff are provided with
access to reporting forms. Below are some initial steps for implementing
- Develop brochures to explain the changes in the legal system
the changes to all staff
- Train a “champion” (or a team)
to be the main focus for the system
- Explain to users how this new
system will fit into the current system
- Have a “Health and Safety
Week” campaign to promote the reporting system
- Include a section
on the reporting system in the safety induction course
- Use email and
internet to communicate; announcing new information, and congratulating
posters to describe the reporting system process pictorially
|Potential Obstacles: Information about the system may
not be disseminated to a wide enough audience and to a deep enough
level within the organization.
8. Developing and Maintaining the Right ‘Culture’
A number of additional issues concerning the ‘cultural’ aspects
of reporting are necessary in order to maintain motivation to report, such
as the trust between reporters and the managers must genuinely exist for the
reporting system to work. The main aims are to develop an open culture in
which people feel able to trust the system and to develop new ways to motivate
people to use the system. Below are initial ideas.
- System visibility – potential contributors to be made aware
of the procedures and mechanisms that support the incident reporting system
the employees’ voice – must ensure that the reports are used
to voice the employees voice and not used to suit existing management
- Publicized participation – publish the contribution rate from
different parts of the organization to show that others have trust in the
system (but must ensure that this doesn’t have the opposite effect,
such as asking for certain quotas of reports per month)
- Develop ‘marketing
strategies’ for enhancing safety culture (see Vecchio-Sadus and Griffiths,
2004): a) Customer centered – focusing the marketing strategy to suit
the audience (e.g. management will have a different focus than the operations
personnel); b) Link safety values to the core business – and show tangible
evidence for their impact, such as how safety can enhance production, efficiency,
communication and even cost benefits; c) Reward and recognition – positive
reinforcement for reporting incidents
- Change attitudes and behaviors
- focus on the immediate, certain and positive consequences of reporting
incidents and publicize the “pay-offs” of reporting incidents
commitment – raise awareness of management’s commitment to safety,
with a “hands on approach”; have management involved in the reporting
process to show that they visibly believe and promote the Just Culture
involvement – ensure employee involvement so they are committed to the
need to be actively involved in decision making and the problem solving process.
|Potential Obstacles: It takes time and persistence
to try and change safety attitudes and behaviors. Maintaining motivation
of the personnel set with the task of improving safety reporting can
be a potential obstacle.
Three planning aspects that need to be taken into consideration: 1) the required
time to undertake the steps and sub-steps (include start and end dates); 2)
the estimated costs involved and 3) who will undertake the work.
reading—A Roadmap to a Just Culture, Case Studies >>>
Reprinted by permission
from the Global Aviation Information Network.