Success of Proactive Safety Programs Relies on "Just Culture" Acceptance

by Mr. Tim Grosz, HQ AMC/A3TO
Chief, Operations Risk Assessment and Management System (Ops RAMS)

2/5/2014 - Spring 2014 --

First, what is "Just Culture"?

A widely accepted and published definition comes from Dr. James Reason, a noted psychologist who has worked in the aviation field with the Royal Air Force Institute of Aviation Medicine and the U.S. Naval Aerospace Medical Institute, and received the 2001 U.S.A. Flight Safety Foundation/Airbus Industry Human Factors in Aviation Safety Award. He writes, "Just Culture is an atmosphere of trust in which people are encouraged to provide safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior."

That sounds great, but what does this really mean, and how does it apply to Air Mobility Command's proactive safety programs? People make mistakes. Yes, believe it or not, even aircrew members, maintainers, and other aviation professionals commit errors. If the error is an "honest" one--the kinds of slips, lapses, and mistakes that even the best people can make--then the individual should not be punished for committing or reporting the error. Don't confuse this with a "no-blame" culture or a "get out of jail free" card. Individuals who willfully engage in behavior that displays misconduct or the intentional disregard for safety must be held accountable for their misdeeds. Airmen who do make an honest mistake should not be placed in the same category as those willful violators.

We, as an institution, can learn a lot from the identification of these self-reported errors to increase awareness of the crew force, focus training programs, and improve the level of safety before an accident happens. That's where the proactive safety programs such as the Line Observation Safety Audit (LOSA), Military Flight Operations Quality Assurance (MFOQA), and Aviation Safety Action Program (ASAP) become so valuable. These programs are designed to gather information from the crew force during everyday activities while not under the increased scrutiny of a checkride or while flying with squadron supervision, which allows for a more realistic opportunity to identify areas where the risk for a potential accident might be mitigated. Rather than being reactive and relying solely on accident investigations to identify aircrew errors, these programs take a proactive view to identify systemic enterprise-wide issues. By identifying and mitigating risks, we can hopefully prevent an accident. We do collect trends from evaluations, but because aircrew are on their "A" game and focused on performing to the highest standards, we don't get a true view of everyday crew activities. For proactive safety programs to be fruitful, a Just Culture must be present.

Just Culture is inherent in the way we execute the LOSA and MFOQA programs. During a LOSA observation, the observer takes copious notes; it routinely takes 6-8 hours to complete the report for each mission. However, nothing that could potentially identify the aircrew is reported: no names, no mission numbers, no tail numbers--nothing. After the reports are sent to the LOSA contractor, they are sorted and categorized to identify trends, both positive and negative, without any identifying information. Once the contractor produces the report and delivers it to HQ AMC/SE, a Safety Investigation Board (SIB) is formed to produce actionable observations and recommendations to mitigate the risks identified during the LOSA.

MFOQA is similarly identity protected. Analysts gather information from the aircraft flight data recorders to evaluate aircrew performance at the aggregate level during all phases of flight, with the current focus on analyzing stable approaches. From this analysis, we can make recommendations on where to adjust training or focus evaluations, make changes to directives or procedures, or change/upgrade aircraft equipment. However, if the gross analysis reveals an outlier (a data point that is well outside the expected range of values), a trusted agent, called a Gatekeeper, is appointed. The Gatekeeper is tasked with protecting the identity of the aircrew while gathering enough detailed information to adequately assess and mitigate the hazard or error identified. If the Gatekeeper suspects misconduct or intentional disregard for safety, the proactive safety process stops, and in line with the tenets of Just Culture, the incident is turned over to the appropriate authority for further investigation.

The program with the largest Just Culture challenge is ASAP, because we rely on aircrew members to self-report. Ideally, the individual identifies the error to the unit chain of command and simultaneously completes an ASAP. This allows analysts at the unit level to correct any local issues while consolidating inputs at HQ AMC for a system-wide analysis of trends and aircrew awareness--that is the long-term goal. In the commercial aviation industry, Just Culture is generally codified and documented in a Memorandum of Understanding (MOU) between the company, the FAA, and the pilot union, and a Letter of Agreement (LOA) between the company and the pilot union. ASAP reports are received and processed by an Event Review Committee, which includes members of the company, the FAA, and the pilot union. No disciplinary action from the company or FAA enforcement action can be taken against an ASAP submitter if the submission is timely (normally within 24 hours from the end of the flight sequence) and does not involve criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification.

Unfortunately, the military cannot have this type of arrangement because we don't have a pilot union, and numerous MOUs/LOAs would be required at multiple levels of command. So, until we can build that complete "atmosphere of trust" from Dr. Reason's Just Culture definition that would obviate the need for formal written agreements, we have built protections into our ASAP processes. ASAPs can be submitted anonymously, but when the submitter provides his or her name, the ASAP program manager redacts it and any other pertinent information (mission number, wing assigned, tail number, etc.) to ensure identity protection before sending it out for review at HQ AMC. In addition, none of this identifying information is posted on the ASAP scoreboard.

We're striving to gain the trust of aircrews and the confidence of leadership at all levels to move us closer to a Just Culture that will enable our proactive safety programs to be as effective as possible. You can help by continuing to support and participate in these programs.