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
1.1 Purpose of Report
This report was developed by the Global
Aviation Information Network (GAIN) Working Group E (Flight Ops /ATC
Ops Safety Information Sharing Working Group) and is intended as an overview
of how aviation
organizations can promote improvements in the level and quality of
reporting of safety information. A Just Culture supports learning from unsafe
in order to improve the level of safety awareness through the improved
recognition of safety situations and helps to develop conscious articulation
of safety information.
The objectives of this report include the following:
- Provide an overview of what is meant by a Just Culture,
- Heighten awareness in the international aviation community of the benefits
of creating a Just Culture,
- Provide a portrayal of Just Culture implemented in aviation organizations
and share lessons learned, and
- Provide initial guidelines that might be helpful to others wishing to
benefit from the creation of a Just Culture.
The report is divided into four main sections:
- Introduction – Presents an overview of GAIN,
Working Group E, and an overview of the issue and rationale for learning
about Just Culture.
- Definitions and Principles – Presents a discussion
of the theories and principles of a Just Culture.
- Creating a Just Culture – Provides information
regarding the benefits of a Just Culture; the changes that may occur in
an organization with a Just
Culture; and some necessary steps to create a Just Culture as well
as some possible obstacles that might be incurred.
- Case Studies – Presents examples of four organizations
that have begun to create a Just Culture (Naviair; New Zealand CAA; United
and Alaska Airlines)
A reference section (of the sources for the report)
is also included. In addition, five Appendices provide further information:
Appendix A: The advantages and disadvantages of various types of reporting
systems (mandatory; voluntary and confidential).
Appendix B: Some possible constraints to achieving a Just Culture.
Appendix C: The perspectives of various aviation organizations
on Just Culture (ICAO, regulatory authorities, an airline, ANSPs, IFATCA,
D: A glossary of acronyms.
Appendix E: A form for readers to provide feedback
on the report.
1.2 GAIN Overview
GAIN is an industry and government initiative to promote
and facilitate the voluntary collection and sharing of safety information
by and among users in the international aviation community to improve
safety. GAIN was first proposed by the Federal Aviation Administration (FAA)
1996, but has now evolved into an international industry-wide endeavor
that involves the participation of professionals from airlines, air traffic
providers, employee groups, manufacturers, major equipment suppliers
and vendors, and other aviation organizations. To date, six world conferences
have been held to promote the GAIN concept and share products with
community to improve safety. Aviation safety professionals from over
50 countries have participated in GAIN.
The GAIN organization consists of an industry-led Steering Committee, three
working groups, a Program Office, and a Government Support Team. The GAIN
Steering Committee is composed of industry stakeholders that set high-level
GAIN policy, issue charters to direct the working groups, and guide the program
office. The Government Support Team consists of representatives from government
organizations that work together to promote and facilitate GAIN in their respective
countries. The working groups are interdisciplinary industry and government
teams that work GAIN tasks within the action plans established by the Steering
Committee. The current GAIN working groups are:
- Working Group B--Analytical Methods and Tools,
- Working Group
C--Global Information Sharing Systems, and
- Working Group E--Flt Ops/ATC
Ops Safety Information Sharing.
The Program Office provides technical
and administrative support to the Steering Committee, working groups,
1.3 Flight Ops/ATC Ops Safety Information Sharing Working
Group (WG E)
A workshop at the Fifth GAIN World Conference in December
the need for increased interaction between air traffic controllers
and pilots on aviation safety issues. A quote from “Crossed Wires: What do pilots
and controllers know about each other’s jobs,” Flight Safety Australia,
May-June 2001, by Dr. Immanuel Barshi and Rebecca Chute, succinctly captures
the need seen by many at this workshop and in the aviation community for increased
collaboration between pilots and controllers. The authors introduce the article
saying, “It is often said that pilots and controllers talk at
each other all day long, but rarely communicate.”
Responding to this need, in January 2002 the GAIN Steering Committee chartered
the Flight Ops/ATC Ops Safety Information Sharing Working Group, designated
Working Group E, to foster increased collaboration on safety and operational
information exchange between flight operations and air traffic operations.
The working group consists of representatives from airlines, pilot and
controller unions, air traffic service providers, regulatory agencies, and
organizations. Working Group E has three main focus areas:
- Promote the development
and creation of a Just Culture environment within the Flight Ops and
ATC Ops communities.
- Identify Flight Ops/ATC Ops collaboration initiatives that improve
safety and efficiency.
- Increase awareness of the benefits of pilot/controller collaboration
and promote such collaboration in training and education programs.
After its formation in 2002, the Working Group concentrated on the second
focus area, surveying air traffic controllers, pilots, air traffic service
providers, and others around the world to learn about existing pilot/controller
collaboration initiatives. Twenty-seven of these initiatives are documented
in the report, “Pilot/Controller Collaboration Initiatives: Enhancing
Safety and Efficiency,” available at www.gainweb.org.
The Working Group and the GAIN Steering Committee realized that in order
for pilots, controllers, and other front line workers to come forward and
share information about potential aviation safety problems, a just culture
environment conducive to such information sharing and collaboration must exist.
Therefore, the working group began an effort to search the literature as well
as identify existing examples of the creation of Just Culture in the aviation
safety community. The results are documented in this report, which was prepared
specifically to address the first focus area. Working Group E hopes this information
will assist other organizations wishing to benefit from the creation of a
Just Culture in their countries and/or organizations.
Another Working Group E product, entitled “The Other End of the Radio,” is
under development and addresses the third focus area.
1.4 Overview of the Issue
Any effective safety information system depends
crucially on the willing participation of the workforce, the front line
workers who are in direct contact with hazard. In aviation organizations,
air traffic controllers, pilots, flight crew, maintenance personnel,
and others who can provide key information about aviation safety problems
solutions. Achieving this reporting requires an organizational climate
in which people are prepared to report their errors and incidents. Engineering
an effective reporting culture must contend with actions whose consequences
have focused on blame and punishment. A “no-blame” culture is
neither feasible nor desirable. A small proportion of unsafe acts are deliberately
done (e.g. criminal activity, substance abuse, controlled substances, reckless
non-compliance, sabotage, etc.) and they require sanctions of appropriate
severity. A blanket amnesty on all unsafe acts would lack credibility in the
eyes of employees and could be seen to oppose natural justice.
What is needed is an atmosphere of trust in which people are encouraged to
provide essential safety-related information, and in which they are also clear
about where the line must be drawn between acceptable and unacceptable behavior.
The Just Culture operates by design to encourage compliance with the appropriate
regulations and procedures, foster safe operating practices, and promote the
development of internal evaluation programs.
reading—A Roadmap to a Just Culture, Definitions and Principles >>>
Reprinted by permission
from the Global Aviation Information Network.