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
Appendix C. Different Perspectives
C1. ICAO perspective
The ICAO position is stated very clear in Annex 13 Section Non-disclosure
of records – para. 5.12: “5.12 The State conducting the investigation
of an accident or incident, shall not make the following records available
for purposes other than accident or incident investigation, unless the
appropriate authority for the administration of justice in that State determines
that
their disclosure outweighs the adverse domestic and international impact
such action may have on that or any future investigations:
- all statements taken
from persons by the investigation authorities in the course of their
investigation;
- all communications between persons having been involved
in the operation
of the aircraft;
- medical or private information regarding persons
involved in the accident or incident;
- cockpit voice recordings
and transcripts from
such recordings; and
- opinions expressed in the analysis of
information, including flight recorder information.
5.12.1. These records shall be included in the final report or its appendices
only when pertinent to the analysis of the accident or incident. Parts
of the records not relevant to the analysis shall not be disclosed. NOTE:
Information
contained in the records listed above, which includes information given
voluntarily by persons interviewed during the investigation of an accident
or incident,
could be utilized inappropriately for subsequent disciplinary, civil, administrative
and criminal proceedings. If such information is distributed, it may, in
the future, no longer be openly disclosed to investigators. Lack of access
to
such information would impede the investigative process and seriously affect
flight safety.”
Related to the subject of non-disclosure of certain accident and incident
records, ICAO has issued a State Letter (dated 31st of January 2002) enclosing
the Assembly Resolution A33-17 (Ref.: AN 6/1-02/14). A copy of the letter
and enclosure has been circulated for information and reference at SRC13 in
February 2002. The letter basically introduces the Resolution A33-17, whereas
the ICAO Assembly “urges Contracting States to examine and if necessary
to adjust their laws, regulations and policies to protect certain accident
and incident records in compliance with paragraph 5.12. of Annex 13, in order
to mitigate impediments to accident and incident investigations”.
C2. Regulatory perspective
The UK CAA (1993) requires that human error events be reported to the Authority
for safety analysis: “where a reported occurrence indicated an unpremeditated
or inadvertent lapse by an employee, the Authority would expect the employer
to act responsibly and to share its view that free and full reporting is
the primary aim, and that every effort should be made to avoid action that
may
inhibit reporting. The Authority will accordingly make it known to employers
that, except to the extent that action is needed in order to ensure, and
except in such flagrant circumstances as described, it expects them to refrain
from
disciplinary or punitive action which might inhibit their staff from duly
reporting incidents of which they may have knowledge.”
C3. An airline perspective
ABC Airlines (Disciplinary policy used by an international air carrier).
ABC Airlines understands that it needs a safe and security culture that embraces
highest corporate and industry standards. To do this, ABC Airlines require
a willingness to address and remedy all operational shortcomings as soon as
possible. This relies on having a comprehensive reporting of all incidents
that pose hazards to the customers, staff or operations. All safety issues
must be reported without exception. The company is committed to the greatest
possible openness in reporting.
“No blame will be apportioned to individuals following their reporting
of mishaps, operational incidents or other risk exposures, including those
where they themselves may have committed breaches of standard operating
procedures. The only exceptions to this general policy of no blame apportionment
relate
to the following serious failures of staff members to act responsibly,
thereby creating or worsening risk exposures.
- Premeditated or international acts of violence against people or
damage to equipment/property
- Actions or decisions involving a reckless
disregard toward the safety of our customers, our fellow employees
or significant economic harm to the company or
- Failure to report safety incidents
or risk exposures as required by standard operating procedures
and / or this policy
Staff who act irresponsibly in one of these ways
remain exposed to
disciplinary action. A staff member’s compliance with reporting requirements
will be a factor to be weighed in the company’s decision-making in such
circumstances. Outside these specific and rarely invoked exceptions, staff
members who make honest mistakes or misjudgments will not incur blame – provided
that they report such incidents in a proper fashion.”
This disciplinary policy reasonably balances the benefits of a learning culture
with the need to retain personal accountability and discipline.
C4. Air Navigation Service Providers
The EUROCONTROL Performance Review Unit (on behalf of the Performance Review
Commission) conducted a survey of the legal constraints, as well as the potential
shortfalls in the national safety regulations that would not support “non-punitive” reporting
in ATM. The report found that the main legal issues of safety reporting are
about personal data protection and the use of safety data, in particular that
arising from the investigation. The respondents thought that it is important
that the reporting system is trusted by all interested parties and that reporters
need to feel that they will not be penalized through public exposure within
or outside their organization for reporting routine, unintentional (honest)
mistakes (see 2.1.3). The particularly with regard to the potential use of
the information in court. Some states have addressed this conflict by offering
protection to parties reporting honest mistakes.
The majority of respondents considered that their States national safety
regulations did not explicitly mandate the implementation of a non-punitive
environment.
Two of the key messages that emerged from the survey were that in many States
there are significant legal constraints to non-punitive reporting in ATM.
As a result many staff feel inhibited to report. This is particularly the
case where States have “Freedom of Information” legislation in
place and where they have not taken steps to protect safety reports from the
application of such legislation. 2) The overwhelming majority of respondents
(including non-European Union States), saw EU legislative proposals as a major
enabler to implement non-punitive reporting.
C5. IFATCA
From the 43rd Annual IFATCA (International Federation of Air Traffic Controllers’ Association)
Conference in Hong Kong in March, 2004, the following comments were discussed
regarding the implementation of a Just Culture. The 2.1.1. IFATCA policy on
page 4 4 2 3 paragraph 2.2 Air safety reporting systems is that:
"Whereas IFATCA thinks a Voluntary Reporting System is essential, MA's
should promote the creation of Air Safety reporting systems and Confidential
Reporting Systems among their members" Additionally, "IFATCA shall
not encourage MA's to join Voluntary Incident Reporting System unless there
is a guaranteed immunity for the controller who is reporting. Any voluntary
incident reporting system shall be based on the following principles:
- In accordance and in co-operation with the pilots, air traffic controllers
and
ATC authorities;
- The whole procedure shall be confidential, which
shall be guaranteed by law;
- Guaranteed immunity for those involved,
executed by an independent body."
See also the section on “Collective Aviation Opinion” from the
43rd Annual IFATCA conference which briefly describes the view points of aviation
organizations on prosecution of employees and the resultant effect on safety.
C6. IFALPA
In a recent statement to the World's media, the IFALPA President strongly
denounced the growing trend of apportioning blame following aviation accidents.
This threat of civil or criminal proceedings for violations of aviation safety
laws and regulations is having a profound and damaging effect on the flow
of precious aviation safety information which is essential if lessons are
to be learned from accident investigations. IFALPA is supported by many prominent
international organizations in its concern.
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