Transcript
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The Just Culture Initiative
Roderick D. van DamHead of Legal Service, EUROCONTROL
ICAO / ASPA Regional Seminar10-11 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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Eurocontrol (37 +European Community)
ECAC (42)EU (27)
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Membership of the EU, EUROCONTROL and
ECAC
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CG
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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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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 Air Traffic Services• Management of an international (4 States) ATC Centre: Maastricht• Development of an international (8 States) ATC Centre: CEATS
EUROCONTROL - CORE BUSINESS
Provision of training, education and knowledge transfer in Air Navigation Services inside and outside Europe
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Setting the scene
Accidents in 2001 & 2002Strengthen the need for continuous safety improvementsLed to, inter alia, creation of Safety Data Reporting and Data Flow Task Force (SAFREP)
SAFREP Report on ATM incident reporting culture: Impediments and PracticesInvolving 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 StatesSafety 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
Maturity (%)
50
55
60
65
70
75
80
2002 2003 2004 2005 2006
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:
Gross negligence, willful violations and destructive acts
Actions, omissions and decisions expected from someone with your level of training and experience
Not tolerated
Not punished
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Concept of Just Culture
Objectives:To provide increase in reportingNot 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 State’s 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
•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
Directivescurrently
under review
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Challenges
Cooperation betweenJustice and ATM/Safety experts
Public interest Safeguards
Respect roles and responsibilitiesAddress grey areas
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Challenges
Communication and trustTrust at all level (ANSPs)
Staff / ManagersBetween ManagersImportant role of management
TrainingReporting is an obligation – part of professional duty
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Challenges
Liability of ATCLack of harmonization
National frameworks
Administrative sanctions
Criminal liability
Disciplinary sanctions
CivilLiability
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Challenges
Trend in Europe: ATC and criminal proceedings
Relatively recent trendFurther to an accident:
Linate caseÜberlingen caseMt-St-Odile case
Further to an incident:Delta case
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Challenges
Increase of criminal proceedings - Why?Basic principles have not changedIncrease awareness of safety mattersNot 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 safetyNeed to ensure flow of informationNeed 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 levelInternational level
However – focus not only on legal framework:Dialogue Justice / SafetyTrust and CommunicationTraining
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Way Forward
Aim for balanceRespecting 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
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