The Just Culture Initiative

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The Just Culture Initiative

• Roderick D. van Dam
• Head of Legal Service, EUROCONTROL
• ICAO / ASPA Regional Seminar
• 10-11 April 2007

European Organisation for the Safety of Air
Navigation
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Outline

• Setting the (European) scene
• Concept of Just Culture
• Challenges
• Way forward European and International
  approaches

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24 Hours of Europe Air Traffic September 10, 2004
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Membership of the EU, EUROCONTROL and ECAC
IS
FI
Eurocontrol (37 European Community) ECAC
(42) EU (27)
RU
NO
SE
EE
XX
LV
DK
KZ
LT
IE
BY
GB
PL
NL
UA
BE
DE
CZ
LU
SK
MD
AT
HU
FR
CH
GE
RO
AZ
SI
HR
AM
BA
SR
IR
BG
IT
CG
PT
MK
TR
ES
AL
GR
IQ
SY
CY
MT
DZ
TN
MA
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EUROCONTROL

• European Organisation for the Safety of Air
  Navigation
• EUROCONTROL Convention
• 13 December 1960
• Amended Convention
• Protocol 12 February 1981
• Revised Convention
• Protocol of 27 June 1997
• Not yet in force however, early implementation
  of certain provisions of the revised Convention

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EUROCONTROL - CORE BUSINESS

• Management of pan-European programmes

• Research Development work aimed at increasing
  Air Traffic Control capacity and safety in
  Europe

• Operation of a Central Flow Management Unit

• Collection of Route Charges on behalf of Member
  States and through bilateral agreements with
  non-Member States

• Provision of training, education and knowledge
  transfer in Air Navigation Services inside and
  outside Europe

• Provision of Air Traffic Services
• Management of an international (4 States) ATC
  Centre Maastricht
• Development of an international (8 States) ATC
  Centre CEATS

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Setting the scene

• Accidents in 2001 2002
• Strengthen the need for continuous safety
  improvements
• Led to, inter alia, creation of Safety Data
  Reporting and Data Flow Task Force (SAFREP)
• SAFREP
• Report on ATM incident reporting culture
  Impediments and Practices
• Involving EUROCONTROL, European Commission,
  IFATCA, IATA, States and ANSPs representatives
• Conclusions and Recommendations
• EUROCONTROL to continue to actively support and
  cooperate with ICAO

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Setting the scene

• European Safety Programme for ATM (ESP)
• Supporting 42 ECAC States
• Safety maturity to a minimum common level by
  December 2008
• High Priority Area Incident Reporting and Data
  Sharing
• Special emphasis on Just Culture

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ATM Safety Maturity in Europe
ANSPs
Regulator
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Concept of Just Culture

• What is Just Culture?
• EUROCONTROL / SAFREP definition
• A culture in which front line operators or
  others are not punished for actions, omissions or
  decisions taken by them that are commensurate
  with their experience and training, but where
  gross negligence, wilful violations and
  destructive acts are not tolerated

Definition to be submitted to next ICAO Assembly
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Concept of Just Culture

• Main elements

Actions, omissions and decisions expected from
someone with your level of training and
experience
Not punished
Gross negligence, willful violations and
destructive acts
Not tolerated
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Concept of Just Culture

• Objectives
• To provide increase in reporting
• Not to justify absence of reporting
• Evolved from punitive-free reporting, blame free
  reporting

• To achieve a balance between interests of
• safety (and protection of safety information)
• while allowing proper administration of justice

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Concept of Just Culture

• Involving a number of players
• States (Regulators, prosecutors, etc.)
• ANSPs
• Reporters (e.g. controllers)
• International / regional organisations
• A number of challenges must be addressed to
  establish Just Culture

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Challenges

• Powers of judicial authorities vs. Protection of
  safety information
• Both addressed by ICAO Annex 13
• Section 4.2 Non Disclosure of records
• Legal Guidance (new) Annex E
• Not purpose of protecting safety information to
  interfere with proper administration of justice
• Protection of qualified safety information under
  conditions is part of a States responsibilities

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Challenges

• Powers of judicial authorities vs. Protection of
  safety information
• Relevant Assembly Resolutions
• A31-10 Urges Contracting States () to
  implement voluntary and non punitive reporting
  systems
• A33-17 Instructs the Sec. Gen. to develop
  appropriate guidance material related to laws and
  regulations to protect certain accident and
  incident records
• A35-17 Instructs the Council to develop
  appropriate legal guidance that will assists
  States () to protect information gathered from
  all relevant safety data collection and
  processing systems, while allowing for the proper
  administration of justice in the State

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Challenges

• European Level same conflict
• Directive 94/56/EC on the investigation of civil
  aviation accidents and incidents
• Directive 2003/42/EC on occurrence reporting in
  civil aviation
• EUROCONTROL
• ESARR 2 and Guidance Material

Directives currently under review

• States shall refrain from initiating proceedings
• (except in case of gross negligence)
• No prejudice from employer
• Without prejudice to applicable rules
• - penal law
• - related to access to information by judicial
  authorities

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Challenges

• Cooperation betweenJustice and ATM/Safety experts
• Public interest
• Safeguards
• Respect roles and responsibilities
• Address grey areas

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Challenges

• Communication and trust
• Trust at all level (ANSPs)
• Staff / Managers
• Between Managers
• Important role of management
• Training
• Reporting is an obligation part of professional
  duty

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Challenges

• Liability of ATC
• Lack of harmonization
• National frameworks

Criminal liability
Civil Liability
Administrative sanctions
Disciplinary sanctions
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Challenges

• Trend in Europe ATC and criminal proceedings
• Relatively recent trend
• Further to an accident
• Linate case
• Überlingen case
• Mt-St-Odile case
• Further to an incident
• Delta case

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Challenges

• Increase of criminal proceedings - Why?
• Basic principles have not changed
• Increase awareness of safety matters
• Not solely affecting aviation
• Impact on reporting
• Vicious circle
• Calls for Just Culture

Less reporting
More incidents/ accidents
Increase in legal proceedings
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Way Forward

• Potential Impact on ATM safety recognised
• Incidents report are essential to ATM safety
• Need to ensure flow of information
• Need to provide environment supporting reporting
  (and address fear of reporting)
• Just Culture concept supporting safety reporting
  in a culture that is just to all concerned

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Way Forward

• To achieve this
• Review and implement applicable legislative
  framework, structures and procedures
• National level
• International level
• However focus not only on legal framework
• Dialogue Justice / Safety
• Trust and Communication
• Training

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Way Forward

• Aim for balance
• Respecting roles and responsibilities of each
  party
• Seek collaborative approach of all concerned
• Use best practices and experiences
• and
• Endorse and further develop Just Culture at
  international level
• Next ICAO Assembly