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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

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

Cover and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
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

Years Prior
April 25th
Fire Narrative
Lessons Learned

U.S. Forest Service Fire Suppression: Foundational Doctrine

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. Introduction

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 acts in order to improve the level of safety awareness through the improved recognition of safety situations and helps to develop conscious articulation and sharing 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:

  1. Introduction – Presents an overview of GAIN, Working Group E, and an overview of the issue and rationale for learning about Just Culture.
  2. Definitions and Principles – Presents a discussion of the theories and principles of a Just Culture.
  3. 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.
  4. Case Studies – Presents examples of four organizations that have begun to create a Just Culture (Naviair; New Zealand CAA; United Kingdom CAA; 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, IFALPA).
Appendix 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) in 1996, but has now evolved into an international industry-wide endeavor that involves the participation of professionals from airlines, air traffic service 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 the aviation 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, and Government Support Team.

1.3 Flight Ops/ATC Ops Safety Information Sharing Working Group (WG E)

A workshop at the Fifth GAIN World Conference in December 2001 highlighted 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 other aviation organizations. Working Group E has three main focus areas:

  1. Promote the development and creation of a Just Culture environment within the Flight Ops and ATC Ops communities.
  2. Identify Flight Ops/ATC Ops collaboration initiatives that improve safety and efficiency.
  3. 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

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, these are air traffic controllers, pilots, flight crew, maintenance personnel, and others who can provide key information about aviation safety problems and potential 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.

<<< continue reading—A Roadmap to a Just Culture, Definitions and Principles >>>

Reprinted by permission from the Global Aviation Information Network.


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