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
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,
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
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
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
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
- Increased safety reporting,
- Trust building, and
effective safety and operational management.
A Just Culture supports
learning from unsafe acts in order to improve the level of safety
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,
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,
the users with regard to the changes and motives of the new system,
for developing and maintaining a safety culture.
In addition, some
expected obstacles to the creation of a Just Culture have briefly
such as the difficulty in changing legal procedures, and persuading
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.
reading—A Roadmap to a Just Culture, Introduction >>>
Reprinted by permission from the Global Aviation Information Network.