1. Job Brüggen CANSO Safety manager ATC The Netherlands
Just Culture
Job Brüggen
CANSO
Safety manager
ATC The Netherlands

3. Source: Commercial aviation accidents, 1958 – 2014, A statistical analysis, Airbus

4. Leadership Safety Management Safety Culture Just Culture
Inspire from the top
Safety Management
Actively managing risks
Safety Culture
The enabler
Just Culture
Rock bottom

7. Why do we need a Just Culture?
Where FEAR is leading, people will not learn to improve, but people will learn not to get caught.
They want to appear good, in stead of be good.
Learning is safer than punishing!

9. Publish your JC Policy
Based on what is internationally recognised as good practice:
The objective of having the JC policy
people are coming to work to give their best effort.
people to perform optimally without fear for unjust punishments.
is encouraging exemplary behaviour
support and protect individuals in their safety tasks
Will be accompanied by practical procedures
Highest organisational level will actively support this JC Policy
Endorsed and committed to by the workforce

10. JC Procedures: protection
Protection of safety data
Safety data, information and records should be protected against access by non-authorised personnel.
de-identification of safety reports, setting access levels,
Protection of reporter
Protecting the reporter is of paramount importance. Names of reporters will never be released. Reports are de-identified.
In case the reporter finds himself charged (on the basis of the report) the organisation will support the reporter as far as reasonably practical.

11. JC Procedures: who draws the line?
A process is described how human behaviour is being interpreted.
The basic structure for judging people's actions is the normal task of the line management, reporting up to the chief executive.

12. JC Who draws the line (2)
A process how the organisation addresses human performance variability.
agree with the workforce what is normal professional behaviour and what is not.
how to interpret human behaviour, whilst protecting the norms and values of incident investigation.
This could take the form of a committee that advises about human behaviour.
Find out what mechanism works best for the company and the workforce.
tools to assist with the interpretation.

13. JC Procedures: Tools
A methodology is available for interpreting human behaviour
Several classification schemes (free or commercial) that could be used for this. Alternatively, an organisation may develop their own scheme.
A classification scheme to help in the interpretation of human behavioiur.
Examples
David Marx
Baines & Simmons
Hearts and Minds

14. JC Procedures: Tools (2)
A flow chart to help in determining a class of human behaviour.
Assisting the interpreter in selecting the right class of human behavior
Ensure that no crucial steps are forgotten, like the routine test (does this happen often?) or the substitution test (could somebody else have made the same error, or: Is everyone doing the same thing?)

15. Promotion
Communications about the existence / application of a Just Culture in the organisation.
Special training programmes to instruct / teach people how to install / maintain a good Just Culture in the organisation.
About JC ‘events’
Legal support
Lead by example

16. Benchmarking with other industries
If possible, current practice may be compared with likewise organisations or industries and useful / good practice can be incorporated in the organisation.
Vice versa, good practice can be shared with other industries or similar organisations.

18. References
Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon
Hearts and Minds available at the Energy Institute
GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment. 
Baines & Simmons. FAiR® System (Flowchart Analysis of Investigation Results)
Reason. Managing Risks of Organizational Accidents.Amazon.
Reason. Human error: models and management. 
Hudson. A new model for a Just and Fair Culture.
Hudson. Safety Culture – Theory and Practice
Eurocontrol Skybrary - Link to Just Culture material
Eurocontrol. Establishment of Just Culture principles in ATM safety data reporting and assessment.
Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for Accidents
David Marx. Whack a mole. The price we pay for expecting perfection.
Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial System
European Commission: EU REG 374/2014
ICAO Safety Of Information Protection TaskForce
Eurocontrol Just Culture Policy