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This article was published as part of ECA`s #ReportingMatters campaign, in which we asked seven experienced pilots and accident investigators (referred to as ECA Just Culture Ambassadors) to write about Just Culture, safety & reporting matters in the aviation industry and beyond.


by Juan Carlos Lozano

In Europe, where Just Culture is a concept that has been recently embraced by almost all major stakeholders in aviation, and has even been incorporated into an EU-wide legislation, we can call ourselves fortunate. However, we all feel that the job has not been completed. There are still things to do and one of such areas where Just Culture has not permeated (yet) is the judiciary system ( or judiciary systems actually). It has been reluctant to accept Just Culture, as a concept.


Why judicial system matters?

Let me start by using a metaphorical example: Justice is the Wembley Stadium compared to Aviation Safety, which is the backyard where my son plays football. And with this I mean that the administration of justice is a fundamental pillar of our society while Aviation Safety is an important need for our globalised world. 

But giving the same weight to both needs is simply a flaw.

I've been acting as a safety advocate for more than a decade and I'll continue to be so; thus by no means I am entailing that safety is not important for our society. What I'm trying to do instead is to put things into the right perspective. And, oddly enough, this is exactly what Just Culture will bring to Justice: it will facilitate putting things into perspective.

Aviation is subject to the same legal processes as any other activity. And when an accident happens, the public demands that those responsible for the safety of air operations are accountable for their actions. However, it is also in the public’s interest that the actions of those who may have contributed to an accident are fully understood; especially in the context of their own organisational and social culture. These two conditions will help providing true lessons that will allow a real reduction of the potential risks of future accidents.

Today, however, we live in a world where litigation is more common than ever. And aviation professionals became seriously concerned with what is perceived as an increased focus on liability issues in aviation safety occurrences.


Misinterpretations and wrong conclusions

One of the biggest fears of aviation personnel is the (mis)use of safety information in legal proceedings. The best (but clearly not the only) example is the information enclosed in safety investigation reports.

Such statements as "the crew failed to..." or "the technician didn't apply the right technique...” - that can be read in investigation reports - are often misinterpreted in the legal world leading to wrong conclusions and severe punishment.

This is exactly what happens today when litigation comes up after an aviation accident. Technical experts representing the different parties concerned normally provide the judge or the prosecutor with a biased view of what happened.  And let’s not forget that the common view that "aviation is safe" goes against the idea of taking risks. But risks are inherent part of aviation.

Thus, instead of eliminating risks from the accepted vocabulary, we need to look at how people, when executing their job decide what is the difference between "risky" and "safe" behavior? And for that we have to look at how people assess what creates ‘risk’.

As Diane Vaughan says in her book ‘The Challenger Launch Decision:

“Each person occupies a different position in the world, which leads to a unique set of experiences, assumptions and expectations about the situations and objects he or she encounters. From integrated sets of assumptions, expectations and experience, individuals construct a worldview, or frame of reference, that shapes their interpretations of objects and experiences. Risk is not a fixed attribute of some object, but constructed by individuals from past experience and present circumstances and conferred upon the subject or situation. Individuals assess risk as they assess everything else-through the filtering lens of individual worldview. Risk is in the eye of the beholder; it can be present or absent in the same situation or object, or, if present, present to a greater or lesser extent."


See it through their eyes

People’s judgement of risks and human behavior can become significantly affected by the effects of hindsight. The outcome of an event will alter the degree to which people feel there is a need for accountability. The same mistake can have very different outcomes.  And a mistake with a bad outcome is actually more likely to be considered "blameworthy" compared to this same mistake leading to a more positive outcome.

Here is where Just Culture can play a paramount role in the judiciary system. Just Culture is not about matching consequences with outcome. With knowledge of outcome, it becomes almost impossible to go back and understand the decisions and actions made by somebody who did not yet have that knowledge of outcome.

Sidney Dekker, author of the famous book "Just Culture", states that

“The challenge if we really want to know whether people anticipated risks correctly is to see the world through their eyes, without knowledge of outcome, without knowing exactly which piece of data will turn out critical afterwards"

The right explanation of why "the crew failed to..." or why "the technician didn't apply the right technique..." will have the potential to change, or not, the decision of a judge to prosecute.

EUROCONTROL and IFATCA, in association with ECA, have developed an ambitious programme called ‘Prosecutor Expert Course’.  The key objective is to bridge the gap between judiciary and aviation worlds by bringing together aviation safety experts and representatives of the judiciary representatives.  

The Course proves to be an effective tool to raise awareness of each side with regards to the needs and difficulties of the other. And their main output is not only to equip expert pilots and controllers with the knowledge and skills necessary to assist prosecutors and judges if there is ever a need to conduct a judicial investigation into an aviation event, but also to educate judicial delegates about the aviation safety technical aspects and to give them some hints about aviation front-end users’ roles and responsibilities in a complex operational environment.

This, interaction and exchange of views between safety experts and judicial representatives, will lead to better, more well-informed judicial decisions and will increase the level of trust of aviation professionals in the legal system. And this is what Just Culture is about.


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