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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

Executive Summary

This report is intended as an overview of how aviation organizations can promote improvements in the level and quality of reporting of safety information. 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. In order for these workers to come forward and report errors or mistakes, an organizational climate conducive to such reporting must exist – a Just Culture.

The report was developed by the Flight Operations/ATC Operations Safety Information Sharing Working Group of the Global Aviation Information Network (GAIN). In providing the report to members of the aviation safety community the working group hopes to achieve the following objectives:

  • 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.

To obtain information for this report, the working group conducted a literature review and gathered information from several aviation organizations that have begun to implement Just Culture principles and concepts. The report provides a discussion of the theories and principles of a Just Culture, information on the benefits of a Just Culture, steps an organization might take to begin creating a Just Culture, and describes cases studies of organizations that have begun implementing Just Culture.

Reason (1997) describes a Just Culture as an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. An effective reporting culture depends on how the organization handles blame and punishment. A “no-blame” culture is neither feasible nor desirable. Most people desire some level of accountability when a mishap occurs. In a Just Culture environment the culpability line is more clearly drawn.

There are a number of benefits of having a Just Culture versus a blaming culture (or indeed a no-blame culture) and the three main ones have been described as:

  • Increased safety reporting,
  • Trust building, and
  • More effective safety and operational management.

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 process of clearly establishing acceptable versus unacceptable behavior, if done properly in a collaborative environment, brings together different members of an organization that might 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.

The report also discuses the following key aspects that need to be addressed in order to improve the quality and quantity of incident reporting through the creation of a Just Culture:

  • Changes to the legal framework that support reporting of incidents,
  • Polices and procedures that encourage reporting,
  • Clear definition of the roles and responsibilities of the people required to implement and maintain a Just Culture reporting system,
  • Feedback to users and aviation community - rapid, useful, accessible and intelligible feedback to the reporting community; and professional handling of investigations and lessons dissemination,
  • Educating the users with regard to the changes and motives of the new system, and
  • Methods for developing and maintaining a safety culture.

In addition, some expected obstacles to the creation of a Just Culture have briefly been noted, such as the difficulty in changing legal procedures, and persuading senior management to commit resources to implementing and maintaining the reporting system.

The report discusses four case studies of organizations that have begun to implement a Just Culture including an airline company, two civil aviation authorities, and an air navigation service provider. These case studies are discussed with regard to changes to their legal systems, the type of reporting system adopted (e.g. voluntary, mandatory, confidential); the implementation process; the roles and responsibilities of the people involved; the reporting procedures; and the methods of feedback to the aviation community.

This document is a first attempt at outlining some of the issues surrounding Just Culture in the aviation community. Its purpose is to provide some preliminary guidance on how to create a just reporting culture and some insights on how to plan the implementation of such a system.

<<< continue reading—A Roadmap to a Just Culture, Introduction >>>

Reprinted by permission from the Global Aviation Information Network.


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