Just Culture in aerospace medicine: balancing safety, accountability and autonomy

Diederik de Rooy, LLM, MD, PhD

Department of Psychiatry,

Leiden University Medical Center

The Netherlands

Disclosure statement

We have no conflicts of interest

21-sep-18Just Culture: balancing safety, accountability and autonomy2

Introduction

Concern for aircrew mental health

EASA action plan & opinion 14/2016

EU-regulation 1042/2018 Alcohol and drugs testing, Psychological testing, Peer support

Consensus-based

Regulations or culture change?

Just Culture for mental health

Focus on mental health, also other health problems (diabetes)

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Outline

What is a Just Culture?

Just Culture in European aviation industry

European Corporate Just Culture declaration

Legal background of Just Culture, especially in European Law

Some ethical remarks Just Culture for mental and other health risks

Balancing safety, accountability and autonomy

Regulatory vs conceptual approach to mental health risks

European situation!

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What is a Just Culture?

Developed in safety-critical industries such as aviation and oil industry

Improving safety by learning from accidents and incidents

Safe reporting possible

Goal: improving future safety but at the same time justice for all involved

In a Just Culture, people are not punished for accidents and mistakes unless they were dishonest, grossly negligent or performed willful misconduct

Balance between providing safety and accountability

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Safety Accountability

Just Culture in Industry

European Corporate Just Culture declaration

Non-legally binding declaration for Just Culture within the context of an organisation

Set of key principles that each organisation is encouraged to implement

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https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiGg8fqjdDXAhWJbxQKHQD8DJQQjRwIBw&url=https://en.wikipedia.org/wiki/Airports_Council_International&psig=AOvVaw2YjqnUIv7yP-jdB2nYYfZ0&ust=1511368843874494 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjR4oGNjtDXAhVLVxQKHUBfBucQjRwIBw&url=http://www.asd-europe.org/&psig=AOvVaw0TBfDp0ciSsc4kYvseC7_L&ust=1511368915735605 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiWs6abjtDXAhVJUBQKHZyvCdAQjRwIBw&url=http://news.gtp.gr/event/era-regional-airline-conference-2017/&psig=AOvVaw10F6Jc4qQFkXt4FfSMZVCe&ust=1511368946085189 https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj759K-jtDXAhUBEBQKHW2mCfAQjRwIBw&url=https://en.wikipedia.org/wiki/File:AEA_Logo2.JPG&psig=AOvVaw267kXEYKjH_E9Bm8GFv1Ii&ust=1511369018036129 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiyhJbKjtDXAhWLbxQKHYhBCkkQjRwIBw&url=http://www.atceuc.org/&psig=AOvVaw0Qj62m_eQI7-YdNqnJtRWL&ust=1511369044630961 https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwihzPPbjtDXAhUHtBQKHZptDe0QjRwIBw&url=https://twitter.com/etfaviation&psig=AOvVaw2zWUTTkjVAnyOb9CfEELXZ&ust=1511369081662928 https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjt9YztjtDXAhXJuhQKHaz7ACsQjRwIBw&url=https://www.canso.org/north-american-dinner-2015-0&psig=AOvVaw2OrwTRaU47ZLwMB4zYiw6Z&ust=1511369116008723 https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjFuNT_jtDXAhXBVhQKHR_cDkgQjRwIBw&url=https://www.airengineers.org/&psig=AOvVaw3rfDMub3uJnxU6NJ37a2i6&ust=1511369153774318 https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjL48iej9DXAhWHSBQKHWFKC3gQjRwIBw&url=https://www.uia.org/s/or/en/1100039897&psig=AOvVaw3aHJblH2lBcvSRonZnr1t0&ust=1511369221741560 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwihh7jGj9DXAhUFPxQKHUJuDusQjRwIBw&url=http://airportregions.org/&psig=AOvVaw1EtVUFhxq28mV-3gYQ_cBX&ust=1511369305021447 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjinZDRj9DXAhWIPBQKHSkfCj0QjRwIBw&url=http://esors.ebaa.org/&psig=AOvVaw1R1fUBZum60B5Iu0x57yLj&ust=1511369327598425 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj04IXcj9DXAhWEuBQKHQlPC9UQjRwIBw&url=http://fs21.formsite.com/IFAIMA/AppMemb/index.html&psig=AOvVaw3gmQ1maNP2qCRuwfFhw07_&ust=1511369350611031 https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj-xYTrj9DXAhXK1xQKHd76D_cQjRwIBw&url=https://www.cargoforwarder.eu/2014/05/26/asa-representing-the-ground-handling-world/&psig=AOvVaw1gDH5TKUM0oAkSO1AlaRbx&ust=1511369382217796 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwig4OCAkNDXAhXIOBQKHX4IArYQjRwIBw&url=http://wideo.co/blog/how-the-european-cockpit-association-achieved-294000-views-on-facebook-with-animated-video/&psig=AOvVaw34CyDMtkdeKt7Kw5xwzQoK&ust=1511369427607918 http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjX1O2ZkNDXAhVDWRQKHbc1AOsQjRwIBw&url=http://www.ifatca.org/&psig=AOvVaw1v2zkyccP3SyuiZAoY9AaB&ust=1511369478880655

European Just Culture declaration

Safety Accountability

Acting safely is a top priority

Despite training, expertise, experience, abilities and good will undesirable outcome

Focus on system performance and contributing factors first

Not apportioning blame and/or focus on individual responsibilities

Reporters are protected from adverse consequences

Positive behaviour and actions should be captured and encouraged

Support provided by organisations, in cases where staff are subject to external procedures

Provide staff with the appropriate environment, tools, training and procedures

Actions, omissions or decisions taken commensurate with experience and training?

Define a process to determine unacceptable behaviour

Document how safety data is managed, stored, protected and disclosed

Understand and accept responsibility with regards to Just Culture principles

Regularly review and assess the maturity of their Just Culture internal rules

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Just Culture in medicine (n=29)

Many, highly different, definitions

Most focus on finding a balance between safety and accountability

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Just Culture and law

Seems to be fundamentally different

Sometimes at odds with civil and criminal law

Civil law: liability and settling damages

Criminal law: provide retribution

Just Culture: future safety

Difficult to ‘survive’ in law

Need for specific regulations (such as EU 376/2014, accident

investigation)

Sometimes informal agreements industry and prosecution office

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Just Culture in (High) Court

High Court England and Wales

Two recent judgements

[2016] EWHC 2279 (Admin) & [2016] EWHC 2280 (QB)

First acceptance of Just Culture in a High Court!

Differentiation accident and criminal investigations Importantly: In accident investigation no protection of criminal

suspect No caution, right to remain silent

Data obtained in safety investigation cannot be used directly in criminal investigation

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Just Culture for (mental) health

No civil or criminal liability, no legal difficulties

Mentioned in EASA-opinion

By EPPSI (European Pilot Peer Support Initiative)

Not specifically mentioned in EU-regulation 1042/2018

However

Alcohol testing: ‘objective, transparent and non-discriminatory’

Peer support ‘non-punitive’ & ‘confidential’

(At least partially) in line with Just Culture principles

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Some ethical remarks

Just Culture carries elements of:

Utilitarianism (Best for society as a whole)  Safety

Deontology (Moral rules are absolute, people never be used as a means)  Accountability

Balance

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