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
4. Case Studies
Four case studies are provided to show the several ways in which different
organizations have attempted to create a Just Reporting Culture (with various
levels of success), including: the Danish (Nørbjerg, 2003), the New
Zealand Civil Aviation Authority (NZ CAA, 2004), and UK Civil Aviation Authority
and Alaska Airline’s systems. These case studies are described under
different headings, depending on the information available.
4.1 Danish System Legal Aspects
In 2000, the Chairman of the Danish Air Traffic Controllers Association described
the obstacles for reporting during an interview on national prime-time television.
This influenced the Transportation Subcommittee of the Danish Parliament to
ask for the Danish Air Traffic Control Association to explain their case.
After exploring various international legislations on reporting and investigating
incidents and accidents, the Danish government proposed a law in 2002 that
would make non-punitive, confidential reporting possible.
The Danish reporting system ensures immunity against penalties and disclosure
but also any breach against the non-disclosure guarantee is made a punishable
offense. The system includes the following:
- Mandatory: Air Traffic Controllers must submit reports of events.
It is punishable not to report an incident in aviation.
- Non-punitive: Reporters are ensured indemnity against prosecution or disciplinary
actions for any event they have reported based on the information contained
reports submitted. However, this does not mean that reports may always
be submitted without consequences.
- Immunity against any penal / disciplinary
measure: If a report is submitted within 72 hours of an occurrence;
if it does not involve an accident; or does not involve deliberate sabotage
due to substance abuse. Punitive measures are stipulated against any
breach of the guaranteed confidentiality.
- Confidential: The reporter’s
identity may not be revealed outside the agency dealing with occurrence
reports. Investigators are obliged to keep information from the reports
- Danish Aviation Authority body (Statens Luftfartsvaesen) implemented the
regulatory framework and contacted those license holders who would
mandatorily be involved in the reporting system: pilots; air traffic
aircraft mechanics and certified airports.
- Danish Air Traffic Control
Service Provider (Naviair)
sent a letter to every air traffic controller explaining the new
system, stating their commitment to enhance flight safety through the reporting
of safety-related events.
- Incident investigators were responsible
for communicating the change, and were given a full mandate and support
- An extensive briefing campaign was conducted to give information
to air traffic controllers; in the briefing process the controllers
expressed concerns about confidentiality and non-punitive issues. These
addressed by explaining the intention of the law governing the reporting
system, the law that would grant media and others no access to the reports
secure freedom from prosecution. Further it was emphasized that no
major improvement in safety would be possible if knowledge about the hazards
was not gathered.
were set up on which reports are dealt with immediately, and on how
much attention is given by the investigators. The investigation of losses
of separation are
investigated thoroughly including gathering factual information such
as voice recordings, radar recordings, collection of flight progress strips
with involved controllers.
- Investigative reports have to be
completed within a maximum of 10 weeks. The reports include the
Aircraft proximity and avoiding maneuvers; safety nets (their impact
on and relevance for the incident); system aspects; human factors;
and recommendations. The ultimate purpose of the report is to recommend
changes to prevent similar incidents.
Increased Reporting: After one year of reporting 980 reports were received
(compared to 15 the previous year). In terms of losses of separation, 40-50
were received (compared to the 15 reported in the previous year).
To Reporters: A new incident investigation department was set up at Naviair
with six investigators and recording specialists. They provide feedback to
the reporter, when the report is first received and when the analysis of the
event is concluded. It is important that the organization is ready to handle
the reports. Feedback is offered twice a year in which all air traffic controllers,
in groups, receive safety briefings (supported by a replay of radar recordings
where possible) and discussions are held of safety events that have been reported
and analyzed. Four issues of a company safety letter are distributed to the
controllers each year.
To the Public: It was acknowledged that, according to the Freedom of Information
Act, the public has the right to know the facts about the level of safety
in Danish aviation. Therefore it was written into the law that the regulatory
authority of Danish aviation, based on de-identified data from the reports,
should publish overview statistics two times per year.
Other Flight Safety Enhancements: flight safety partnership- a biannual meeting
with flight officers from all Danish airlines is held to address operational
flight safety in Danish airspace
- Trust/confidentiality – one break in this trust can damage
a reporting system, and that reports must be handled with care.
nature – it is important that information from self-reporting not be
used to prosecute the reporter.
- Ease of reporting – Naviair
uses electronic reporting, so that controllers can report wherever they have
access to a computer.
- Feedback to reporters – the safety reporting
system will be seen as a “paper-pushing” exercise if useful feedback
is not given.
- Safety improvement has been assessed by Naviair,
where they think information gathering is more focused and dissemination
4.2 New Zealand – CAA Overview
In 1999, the NZ CAA became interested in “Just Culture”, and
started the process of learning how it functions, and the process required
to implement it. They are frequently faced with making decisions regarding
the choice of regulatory tool that is appropriate to apply to an aviation
participant when there is a breach of the Civil Aviation Act or Rules,
and they saw the “Just Culture” model as holding the promise of
promoting compliance and facilitating learning from mistakes. However, to
fully embrace ‘Just Culture’ in New Zealand, there will need to
be some legislation changes and considerably more selling of the concept to
the aviation industry (particularly at the GA end) in order to get the necessary
paradigm shift (away from fear of the regulator when considering whether or
not to report occurrences).
New Zealand operates a mandatory reporting system, with provision for information
revealing the identity of the source to be removed if confidentiality is requested
(the latter happens only rarely).
The reporting requirements apply to all aircraft accidents and to all serious
incidents except those involving various sport and recreational operations.
In addition to the notification requirements for accidents and incidents,
the rules require the aircraft owner or the involved organization notifying
a serious incident to conduct an investigation to identify the facts relating
to its involvement and the causal factors of the incident. A report of the
investigation is required within 90 days of the incident, and must include
any actions taken to prevent recurrence of a similar incident.
Information received under this mandatory reporting system cannot be used
for prosecution action, except in special circumstances such as when false
information is supplied or when ‘unnecessary danger’ to any other
person is caused. (Ref New Zealand Civil Aviation Rule CAR Part 12.63.)
Just Culture Seminars – the NZ CAA invited relevant people in the aviation
industry (including large and small airline operators) and CAA personnel to
attend a seminar by a leading expert on Just Culture. The seminars were extremely
well received by all attendees, thus giving the CAA confidence that Just Culture
principles were appropriate to apply in a safety regulatory context.
The NZ CAA has a set of tools that they apply to an aviation participant
when there is a breach of the Civil Aviation Act or Rules. The tools are many
and varied and form a graduated spectrum from a simple warning, through re-training
and diversion, to administrative actions against Aviation Documents and prosecutions
through the Court. The CAA base their decisions on information which arises
from a variety of sources such as: a CAA audit, an investigation of an accident
or incident, or a complaint from the public.
For the past four years, the CAA has been using Just Culture principles to
a) Information from a safety investigation into a mandatory reported occurrence
should cross the “Chinese wall” to be used in a law enforcement
investigation. (In this context they are using Just Culture to draw the line
at recklessness as a surrogate for "caused unnecessary danger",
which is the terminology used in the relevant NZ Civil Aviation Rule, CAR
b) Document suspension/revocation is appropriate.
c) Education or re-examination is appropriate.
The perhaps natural tendency for a regulatory authority to draw the line
below negligence is resisted. By drawing the line below recklessness when
making decisions, the CAA believes it will encourage learning from human errors
and, once the approach becomes universally understood and accepted by the
aviation community, the incidence of non-reporting of safety failures will
Lessons Learnt – Legal Aspects
Application of the ‘Just Culture’ in the manner described above
requires the Director to exercise his discretionary powers. However, the NZ
CAA does not believe it can fully convince the aviation community that the
Director will always follow a ‘Just Culture’ approach while the
current wording of certain sections of the Civil Aviation Act (S.43, S.43A
and S.44) remains. This is because these sections, which draw the line at ‘causing
unnecessary danger’ and ‘carelessness’, effectively outlaw
human error that endangers flight safety, irrespective of the degree of culpability.
They believe this is the reason why many in the aviation community think twice
before reporting safety failures to the CAA and indicates the need for confidential
reporting. In order to improve reporting, these sections of the Act need to
be amended to raise the level of culpability to recklessness (gross negligence)
before the particular behavior constitutes an offence.
4.3 UK – CAA MOR (Mandatory Occurrence Reporting System)
The UK CAA
has recently reviewed the MOR system to try to improve the level of reporting
within the UK aviation community. The objectives of the MOR are to:
- Ensure that CAA is informed of hazardous or potentially hazardous incidents
- Ensure that the knowledge of these occurrences is disseminated
- Enable an assessment to be made and monitor performance standards
that have been set by the CAA.
Assurance Regarding Prosecution - The UK CAA gives an assurance that its
primary concern is to secure free and uninhibited reporting and that it will
not be its policy to institute proceedings in respect of unpremeditated or
inadvertent breaches of law which come to its attention only because they
have been reported under the Scheme, except in cases involving failure of
duty amounting to gross negligence. With respect to licenses, the CAA will
have to take into account all the relevant information about the circumstances
of the occurrence and about the license holder. The purpose of license action
is to ensure safety and not to penalize the license holder.
The CAA has the following responsibilities: i) evaluate each report; ii)
decide which occurrences require investigation by the CAA iii) check that
the involved companies are taking the necessary remedial actions in relation
to the reported occurrences, iv) persuade other aviation authorities and organizations
to take any necessary remedial actions, v) assess and analyze the information
reported in order to detect safety problems (not necessarily apparent to the
individual reporters); vi) where appropriate, make the information from the
reports available and issue specific advice or instructions to particular
sections of the industry; vii) where appropriate, take action in relation
to legislation, requirements or guidance. The Air Accidents Investigations
Branch (AAIB) investigates accidents, and these are passed on to the CAA for
inclusion in the MOR.
Pilots; persons involved in manufacturing, repair, maintenance and overhaul
of aircraft; those who sign certificates of maintenance review or release
to service; aerodrome licensees/managers; civil air traffic controllers; persons
who perform installation, modification maintenance, repair, overhaul, flight
checking or inspection of equipment on the ground (air traffic control service).
a) Any person specified above should report any reportable event of which
they have positive knowledge, even though this may not be first hand, unless
they have good reason to believe that appropriate details of the occurrence
have been or will be reported by someone else. b) Types of incidents:
i) any incident relating to such an aircraft or any defect in or malfunctioning
of such an aircraft or any part or equipment of such an aircraft being an
incident, malfunctioning or defect endangering, or which if not corrected
would endanger, the aircraft, its occupants, or any other person
ii) any defect in or malfunctioning of any facility on the ground used or
intended to be used for purposes of or in connection with the operation of
such an aircraft or any part or equipment of such an aircraft being an incident,
malfunctioning or defect endangering, or which if not corrected would endanger,
the aircraft, its occupants, or any other person.
Submission of Reports
CAA encourages the use of company reporting systems wherever possible. Reports
collected through the company are filtered before they are sent to the CAA
(to determine whether they meet the desired criteria of the CAA). The company
is encouraged to inform the reporter as to whether or not the report has been
passed on to the CAA.
- Individuals may submit an occurrence report directly to the CAA, although
in the interest of flight safety they are strongly advised to inform their
employers. - Reports must be dispatched within 96 hours of the event (unless
exceptional circumstances), and informed by the fastest means in the case
of particularly hazardous events. - Confidential reports – can be submitted
when the reporter considers that it is essential that his/her identity not
be revealed. Reporters must accept that effective investigation may be inhibited;
nevertheless, the CAA would rather have a confidential report than no report
at all. Processing of Occurrence Reports
The CAA Safety Investigation and Data Department (SIDD) processes the reports
(and is not responsible for regulating organizations or individuals). They
evaluate the occurrences that require CAA involvement; monitor the progress
to closure and follow-up on open reports; disseminate occurrence information
through a range of publications; record reports in a database (names and addresses
are never recorded in the database); monitor incoming reports and store
data to identify hazards/potential hazards; carry out searches and analyzes
response to requests within the CAA and industry; ensure effective communication
is maintained between AAIB and CAA in respect of accident and incident
investigation and follow-up. Confidential reports are directed to and reviewed
by the Head
of SIDD, who initiates a dis-identified record. The Head of SIDD contacts
the reporter to acknowledge receipt and to discuss further; after discussions
the report is destroyed; and the record is be processed as an occurrence,
but annotated as confidential (only accessible by restricted users).
4.4 Alaska Airlines
The following section was taken from a corporate statement
from Alaska Airlines that was transmitted to all staff.
Generally, no disciplinary action will be taken against any employee following
their participation in an error investigation, including those individuals
who may have breached standard operating procedures. Disciplinary action will
be limited to the following narrow circumstances: 1) An employee’s actions
involve intentional (willful) disregard of safety toward their customers,
employees, or the Company and its property. This is applicable when an employee
has knowledge of and/or intentionally disregards a procedure or policy. Reports
involving simple negligence may be accepted. In cases where an employee has
knowledge but still committed an error, the report may be accepted as long
as it is determined that the event was not intentional and all of the acceptance
criteria listed herein is met.
2) An employee commits a series of errors that demonstrates a general lack
of care, judgment and professionalism. A series of errors means anything over
one. Management retains the discretion to review and interpret each situation
and determine if that situation demonstrates a lack of professionalism, judgment
or care. When determining what reports are acceptable when a series of errors
are involved managers should consider the risk associated with the event and
the nature and scope of actions taken as a result of all previous events.
A risk table is available to assist managers in making a determination of
3) An employee fails to promptly report incidents. For example, when an employee
delays making a report in a reasonable time. A reasonable time for reporting
is within 24 hours. However, reports should be submitted as soon as possible
after the employee is aware of the safety error or close call.
4) An employee fails to honestly participate in reporting all details in
an investigation covered under this policy. For example, an employee fails
to report all details associated with an event, misrepresents details associated
with an event, or withholds critical information in his/her report.
5) The employee’s actions involve criminal activity, substance abuse,
controlled substances, alcohol, falsification, or misrepresentation.
The Alaska Airlines Error Reporting System (ERS) is a non-punitive reporting
program which allows employees to report to management operational errors
or close calls that occur in the workplace. This system is designed to capture
events that normally go unreported. It also provides visibility of problems
to management and provides an opportunity for correction.
Roles and Responsibilities
The Safety Division has oversight of the program. Supervisors and local management
have responsibility for the day-to-day management of reports submitted, investigations
performed and implementation of corrective actions.
Users: Any employee not covered by the Aviation Safety Action Program (ASAP)
or Maintenance Error Reduction Policy (MERP). These employees are not covered
by ERS because they are certificated by the FAA, and the company cannot grant
immunity to them in all cases. ASAP provides protection for certificated employees.
Pilots and Dispatchers are currently covered under ASAP. Until Maintenance & Engineering
develops an ASAP, Maintenance & Engineering employees will be covered
1. Reporters can file a report on www.alaskasworld.com. An employee can also
submit a report over the phone by contacting the Safety Manager on Duty. 2.
A report should be promptly submitted, normally as soon as the employee is
aware of the error or close call. Reports made later may be accepted where
extenuating circumstances exist.
The employee’s supervisor will review the report, determine if it meets
all criteria for acceptance and notify the employee. If the report is not
accepted, the employee’s supervisor is responsible for contacting the
Safety Division immediately for review. Concurrence from the Safety Division
is required prior to the non-acceptance of a report. The Safety Division will
record and review all reports submitted under this program. The Internal Evaluation
Program (IEP) will accomplish a monthly review of corrective actions. All
long-term changes to procedures and policies will be added to the IEP audit
program and become permanent evaluation items for future audits. A summary
of employee reports received under this system will be presented to the Board
of Directors Safety Committee quarterly. Summary information will also be
shared with employees on a regular basis.
reading—A Roadmap to a Just Culture, References >>>
Reprinted by permission from the Global Aviation Information Network.