Just Culture

How a Compliance Philosophy is Rewriting Safety

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A lot of the Safety Matters articles thus far have focused on various programs that enhance safety by collecting data, and using that data to develop policies and procedures to drive overall safety to a higher level. The one aspect of recent safety success, that has not yet been discussed here, is the human side of the equation. It is probably obvious to any reader that if an organization is geared toward harsh punishment for mistakes, then for fear of punishment, most reasoning people will simply not report issues or hazards they encounter.

Since the single component most critical to the success of all of the safety programs is participation by employees or contractors of a company, then it goes without saying that if a program provides punishment or “enforcement” without consideration of circumstances, then those people will simply not participate at the level needed to maximize success.

Most people who have been flying for a long time will be familiar with the concept of enforcement. Simply stated, if a pilot was caught not adhering to a regulation, policy, standard, etc., they were simply violated or failed by an examiner or enforcement agent (such as an FAA inspector) and a legal process was begun against that person. This is the old safety philosophy of “adherence is safety,” meaning that if a regulation is never broken, then an operation was automatically deemed “safe.” We know from what was learned from a variety of accidents that this philosophy simply was not as effective in preventing accidents as the various systems that we have already discussed in this column. Enforcement leads to a culture of non-reporting for fear of violation, revocation, or criminal charges against the individual reporting. We have probably all seen this in the form of “we will just say that we didn’t know it was broken,” or “we shouldn’t volunteer anything that isn’t asked.”

As we discussed in the past article about the Aviation Safety Reporting System (ASRS), pilots simply did not trust the FAA with voluntary disclosure and the program failed miserably – until it was handed off to NASA as an independent third party that ensured that everything was de-identified and used only in the interest of safety data gathering rather than enforcement. As soon as the possible threat of enforcement was removed, data started to pour in. There was also an added protection that if the person filing the ASRS did not act to intentionally break a rule or undermine safety, they were allowed to use the ASRS as a means to avoid violation should the FAA find out who the person was. This enhanced participation further because not only did it allow pilots to voluntarily disclose their errors and mistakes, but it also provided a means of reasonable protection for doing so.

This provides the basis of a just culture which is fundamental to all modern safety programs. In designing programs like ASAP, FOQA, MOQA, LOSA, SMS, etc., to focus solely on the safety aspect of the reports and provide protections for the reporting individual, we see higher rates of success and participation in comparison to programs that do not provide protection. In order to improve safety, even most modern programs that interface directly with the FAA, such as ASAP, have explicit and clear protections that are legally binding for those submitting the reports.

It is with this understanding, and the data to support it, that in 2015, the FAA began to transition into a “compliance philosophy” and started moving away from a strict “enforcement” policy they had used in the past. It has been a controversial issue among certain hard-liners who still believe “adherence is safety” and that the new philosophy has no teeth for enforcement. This is patently false. The compliance philosophy simply shifts the focus from enforcement action to attempting to correct the root issue through retraining, relearning, discussion, and other techniques that seek to resolve the fundamental issue, as opposed to immediately punishing it. The data overwhelmingly support the notion that enforcement is not as effective as compliance in most cases. This is directly evidenced by the massive, exponential strides in safety that have occurred as more and more compliance-type programs have been implemented. However, make no mistake, there are still plenty of enforcement options available to the FAA should it be found that any incident fell outside of the criteria and protections of a compliance program. In other words, a willful and intentional violation of a regulation will still likely be met with enforcement action as opposed to compliance action due to the nature of the violation.

However, in the clear majority of cases, violations either occurred due to a loss of situational awareness, lack of understanding, normal human error, or some other factor that basically resulted in an “honest mistake.” It seeks to use the understanding that aviation is highly complex and highly challenging which can make the chance of a mistake more likely.

With the new compliance philosophy, the FAA seeks to replace legal action with correction of underlying safety deficiencies using engagement, root cause analysis, transparency and information exchange between the FAA and the certificate holder.

This is referred to as a Just Culture because it understands and acknowledges the inevitability of human error, the mistakes that result from human error, and the fact that in most cases, these mistake were not intentional. However, since even a basic and unintentional mistake can have grave safety consequences, the FAA must seek \ to resolve the issues as quickly, effectively and efficiently as possible.

It should also be understood that in the event of compliance action, the certificate holder does not waive any of their fundamental legal rights in the process, since the over-riding focus is to solve a root safety issue without resorting to enforcement. Just as the compliance philosophy has been crucial to achieving safety improvements in all other aspects of the industry, I believe the FAA’s adoption of it has the opportunity to provide profound and far-reaching changes in safety that may not have otherwise been possible.

In next month’s article, we will talk about the various factors that will pretty much exclude any action taken by a certificate holder from compliance, and into the realm of enforcement. ACN

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