Just Culture @ Austro Control - Entry Point North · Source: Adopted from Just Culture Training...
17
DIESER TEXT DIENT DER NAVIGATION Just Culture @ Austro Control JC implementation from an operational point of view
Transcript of Just Culture @ Austro Control - Entry Point North · Source: Adopted from Just Culture Training...
DIESER TEXT DIENT DER NAVIGATION
Just Culture @ Austro Control
JC implementation from an operational point of view
2
Who wants change?
3
Just Culture is…
Blame CultureBlame-Free Culture
Just Culture
Supp
ort o
f Sys
tem
Saf
ety
Source: Adopted from Just Culture Training John Westphal Outcome Engineering (2010)
4
The Regulator says…
Source: EU Reg 376/2014
5
The Judiciary says…
“There are activities in which the degree of professional skill which must be required is so high, and the potential consequences of the
smallest departure from that high standard are so serious, that one failure to perform in accordance
with those standards is enough to justify dismissal.”
1899-1999 UK Judge
Source: Adopted from Just Culture Training John Westphal Outcome Engineering (2010)
(Überlingen 2002) (Milano Linate 2001) (Turkish, 2009)
6
The System View is…
“People make errors, which lead to accidents. Accidents lead to deaths. The standard
solution is to blame the people involved. If we find out who made the errors and punish
them, we solve the problem, right?
Wrong. The problem is seldom the fault of an individual; it is the fault of the system.
Change the people without changing the system and the problems will continue.”
Don NormanThe Design of Everyday Things
Source: Adopted from Just Culture Training John Westphal Outcome Engineering (2010)
The Expert View is…
7
System Design
Behavioural Choices
Adverse Outcomes
Human Errors
Working it here (80%) Before it leads to here (20%)
e.g. Procedures, Equipment, Training etc.
Source: Adopted from Just Culture Training John Westphal Outcome Engineering (2010)
Presenter
Presentation Notes
Work the system design and behavioral choices 80% of the time because that’s how you can have the greatest impact on the types of outputs your system produces. If your spending most of your time on the right you have become a firefighter running around all day long putting out fires never really having the opportunity to learn.
The Policy says…
8
Where do we draw the line?
9
Presenter
Presentation Notes
How to deal with personal needs on shift/duty?
Three Behaviours
1010
Unintended ActionsUnintended Consequence
HUMAN ERROR
Error
Intended Action Unintended Consequence
AT-RISK BEHAVIOUR
Unintentional violation(Mistake)
Reckless Behaviour
Intended ActionIntended Consequence
RECKLESS BEHAVIOUR
Sabotage
CONSOLE COACH DISCIPLINE
Intentional violations
Intentional Violation for personal gain
System (Substitution) TestRepetitive Behaviour (Routine) Test
Source: Adapted from David Marx (JC Algorithm) and Baines & Simmons (FAIR)
Improvement Measures
11
Human Error(„honest mistake“)
At-Risk Behaviour Reckless Behaviour
Product of our current System Design
Manage through changes in:• Processes• Procedures• Training• Environment/ Conditions• And so on….
A Choice: Risk believedinsignificant or Justified
Manage through:• Removing incentives for at-
risk behaviour• Creating incentives for
healthy behaviours• Increasing situational
awareness (risk perception)
Conscious Disregard of Unjustifiable Risk
Manage through:Remedial action ORDisciplinary action• Warning• Note on file• Replacement• Degradation• Removal of Bonus• Dismissal
System Re-Design Coaching Discipline
Tolerated Not tolerated
Source: Adapted from David Marx (JC Algorithm) and Baines& Simmons (FAIR)
How does it work @ Austro Control?
12
Code of Conduct
Collective Argeements
Employment Law
OccurrenceReport
Safety Investigation
SystemicImprovements
Just Culture Committee
Individual Measures
through Line Manager
Safety Investigation
Process
Human Ressources
ProcessFor more info contact: Michaela Schwarz (Safety Management/ Human Factors) [email protected]
Presenter
Presentation Notes
Just Culture Process is independant from HR processes. If potential yellow/red then JC committee.
JC Committee @ Austro Control
13
#1 Operational Safety
Manager
#2 Local Safety Committee
Member
#3 Human Ressource
Expert
#4 Human Factors/Just Culture Expert
Line Manager/ Staff rep. upon request, but anonymous and no voting right.
3:1
Just Culture Tool (Excerpt)
14
√ Fair and Just√ Objective√ Transparent
© Outcome Engenuity www.justculture.org
My role in the JC context
15
Role ResponsibilityManager Promotion/ Communication and implementation of Just Culture principlesSafety Investigator Adherence to just culture principles during safety investigation, „just“
language, focus on why things happened,
Operational Safety Manager
Operational expertise and safety management system view
Local Safety Committee
Operational staff – local rationale/ practices
Human Resources/Legal Expert
HR/ legal expertise
Just Culture/ HF Expert
Expert on JC principles and tool, facilitation of committee and contact to line management
Auditor/ Surveyor Compliance check against just culture principles, just culture „maturity“Staff Union Reps Observer in Just Culture Committee, no voting rightsStaff Association Rep. Observer in Just Culture Committee, no voting rights
All staff Duty of care to report all hazards, just culture awareness
Examples in the ANS context
What would you do, if someone…
…climbs/descends aircraft without prior release…uses the mobile phone in position…leaves the position to get a coffee…performs a maintenance task from memory…issues a MET product late…does not file a mandatory report
16
Contact:
Arno LeimlehnerAir Traffic Controller
Austro Control GmbHATM/ENRO/ACC-FICSchnirchgasse 11BA 1030 Wienwww.austrocontrol.at
T: +43 (0) 5 1703 2117M: +43 664 521 75 81Email: [email protected]
17
