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Challenges in adopting a “just culture policy” in operational “front line” organizations and how this affects safety

Kougioumoutzi Maria

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Summary

"Just Culture" is related to the achievement of safety within an organized Safety Management System, within complex systems. It advocates a culture of balance between accountability and fair treatment for mistakes made while working within an organization, that is, not punishing mainly "front-line" operators, but always excluding cases of gross negligence, deceit or destructive acts. This perception applies to adequate operators who, while acting in accordance with their training, face such a situation which ultimately results in an unpleasant result. Even if it does not mean immunity or impunity, the implementation of such policies and their full integration into an organization or legal framework is an exercise of balance. This paper will summarize a few theories about human error and how it is addressed in traditional or more advanced theories in complex systems. It will also refer to the possible effect that cognitive biases may have in the process of explaining an error such as the hindsight bias. It will present briefly how safety management systems are implemented in practice. In addition, examples that are related to the mentioned issues, from the field of Aviation, are mentioned. The principles of just culture support the notion that safety in an operational environment improves when stakeholders are encouraged to report unsuccessful actions, bad judgment or mistakes, incidents or events that have affected safety, and the circumstances that led to them without the fear of punishment. In EU area, EC 376/2014, on Occurrence Reporting, is already applied in the field of air navigation, which is a pioneer in the field of implementing safety policies. Just Culture, however, can be applied in many different domains. As an example, we can include the health sector and the rail sector in Europe. The introduction and implementation of a Just Culture policy in an organization faces many challenges, both within the organization and outside it. For example, in the event that, an accident has occurred, this situation is dealt with outside the organization and there is a judicial procedure and consequently a judgment. Some of the issues presented include the procedure that is used to investigate incidents/occurrences and also the problems that occur from the understanding of work only “as it is imagined” and not as it is actually done. These are some of the challenges within the organization. At the judicial level challenges exist in the penal systems of the sovereign states and in general the harmonization of the law, the media, the training and the acceptance in this “just culture” mentality from the judicial system in general. At the same time, the necessary compensation of the victims that might exist as a result of an error should not be ignored. The TOKAI digital platform has been developed and launched in Europe, and in other regions for the reporting of occurrences. This platform is now used by most Air Navigation providers for incident reporting and investigation. This thesis will present shortly the functions of this platform. In addition, questionnaires that developed in the context of a relevant survey will be analyzed regarding the just culture. These questionnaires had responses from operational staff of the HCAA / GDFPYAN. Correlations were made in selected items of the survey with the use of SPSS. Finally, the survey will present interviews completed by HCAA operational employees, as well as interviews given by court officials.

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