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

by VG (ECA)

“There was this beer call list; you know the one where you collect money after each stupid thing you do, and then at the end of the month, the one with the worst record needs to take the team out for a beer. After a take off during my helicopter training, I felt something was wrong, so I returned. It was probably not necessary, but I wasn't sure. So, of course, some colleagues were already teasing me about the beer call, but then the chief-pilot deleted my name. He said `I don’t want anyone who turns back for technical reasons to be punished.' This was my first Just Culture moment I encountered, and it was back in 1980.”

We meet Renault Bosma at the Headquarter of ECA; the office that is easily his second base.  As the Chairman of the Flight Data Working Group, and a veteran helicopter and commercial pilot, he knows the industry inside out. He feels content that he can help the process of sustaining and encouraging a safe aviation, and he does so since the implementation of EC Directives 2003/42 Occurrence reporting in civil aviation in 2003. The industry came a long way since then, and so did Renault: following a decade of Navy career, working over 24 years at Transavia and, today, flying as a freelancer with TUI. Within minutes, we have a grasp of Renault; he became a commercial pilot by `accident` as he diverted away from helicopter flying; believes that the aviation industry is safe but we need to take deliberate actions to keep it even safer; and after almost four decades of flying he is still awestruck by the sunrise during an early take–off.  But we wanted to go beyond the layers, and he was ready to let us in. Inasmuch as that he talked to us in a pilots` jargon introducing us to terms as Alfa, Bravo, Charley, Delta, or when burning fuel comes handy before landing.

 “I got into a bird strike in Amsterdam; lots of birds and also heavy showers. One of the engines was damaged, and I wasn't sure about the other. So we decided to burn some fuel before landing as we were still over the maximum landing weight, and landing with that overweight back then was something unusual. We landed in 30 minutes after the showers we passed. But our decision was challenged by the Chief Pilot afterwards.” Renault talks openly about blaming. Though, as he admits, he was never directly blamed, he feels that the “you should have done that” is a form of blaming and it certainly hurts the culture of the industry. “Did you consider doing otherwise? – would be a much healthier approach.” 

Blaming and shaming are among the main reasons why pilots– and people in the industry, in general – are reluctant to report. Renault, however, can't complain; he was lucky to grow up in and into a Just Culture. And even if there are things to improve the “intention” is clearly there. Not knowing what happens to a report and what consequences you need to bear are powerful stop signs to anyone in the industry. “Of course, the precondition is that you`re not doing something dull deliberately,”says Renault while he wants to make sure his message about Just Culture is clearly conveyed. And that is: “If there is a mistake, to see the intention is a game–changer. If the intention is on the right side (it was an honest mistake), you shouldn't be blamed. But you’re still accountable. And the more experience you have, the more accountable you’re.” 

To demonstrate his approach, he used a blunt, yet practical example from life; when a 3–year–old kid tucks a sandwich into the video recorder, it`s an honest mistake. But if a 15–year–old does the same, that is a deliberate action.  And, of course, there are times when you break a rule deliberately, but then, the question is: Did the outcome get better by breaking the rule?

After all, the name of the game is trust. “You work with humans on both the pilots and the management sides. If there is trust between them, you have already reached a fair level of Just Culture.” We learn that working in The Netherlands is being on the safe side in the aviation industry. However we hear stories from other countries or airlines; and though they are just stories, “if there is smoke, there is fire, isn't it?”

Reporting is not only to fulfill an obligation; it also offers, – and for that, of course, we need some level of Just Culture at least – a fantastic learning opportunity. “You got this big screen and part of it’s a 3D flight presentation, and you can re–experience what you did. Just imagine”, explains Renault further, “you’re confident you made an approach, stable at 500 feet, but this simulator shows that it was only 200. The difference between your perception and the reality can be significant. Next time, if you think you’re stabilized at 600, you will know that most probably you’re at 500. And this is amazing.”

This and any other post–incident, post–occurrence management system helps to ease the concerns. From one hand, management needs to convince people to report and prove that reporting aims at safety and not at punishing. On the other hand, they need to show their people what they do with the information, giving them a chance to re–live what happened instead of threatening that next time ’you would be fired’. “I believe in Just Culture. This is the only way to be open about mistakes and have trust on both sides that those incidents are treated with care. Pilots and management should cooperate to discover deficiencies, mistakes; maybe it has a background in training, economical or structural setup. It’s worth to put some effort into it and find out the whys.”

Once rumours start, it’s easy to see what happened and who did it. If we stop here, we encourage the comfortable blaming culture. If we go beyond that and rather expand our question as to ‘why did that happen?’ we immediately refrain from blaming. “If we know the why, we certainly know who, and what, but why is more important.”

And here we crave to go even further, we want to know what makes a good who today. To be more precise:  has the definition or requirements of a good pilot changed over the years? The answer is yes. 20–30 years ago pilots were educated on basic flying. Today, they need basic flying and the ability to manage automation. But this is not only a change in technology but a shift in the mindset. For this latter, the new generation is certainly winning over Renault’s generation. As he admits “I catch myself sometimes that I really need to study a new automation system, and it’s not for nothing that we often get a young co–pilot, who grew up with all these digital gadgets.” It’s, however, not to say, that mixing two distinct generations in a cockpit is the ultimate solution.

A good pilot today needs to be aware of both flying modes equally, and if the automation is in malfunctions, or if it doesn't do what you want it to do, you need to refer to the basic flying. It’s hard not to bring up the case of Air France 447, where automation, the not understanding of what was happening, the contradicting sign, without a solid understanding of basic flying were a trap to fall into.

It came as no surprise at this point that Renaults would pick “the ability of working together” as the featured skill any pilot should seize today. Whereas, being overconfident and saying that 'things will not happen with me' is simply a no–go. “How could it happen to him?”– adds his suggestion towards an attitude that builds the great pilots of the future.

And he might be thinking of his son when he sets these basic thresholds for aspiring pilots. “My son is flying as well.” Thus, it might be too late to ask if he would advise his children to choose this profession; we ask it none the less. “He’s flying already. But today?  To start today? I am not sure I would advise him.”

Such as many of the pilots, Renault would not worry about his son because of safety, but rather because of uncertainty. It’s known that today the conditions to become a pilot are burdensome. Paying 150 thousand EUR for pilot education is a norm. Let alone those incidents when the school goes bankrupt in half way and the student needs to start from scratch. But even graduating doesn't mean the struggle is over: finding a job is challenging, most of the fresh pilots would join a small airline, and pray that it doesn't go bust until they gather enough flying hours to apply for another job. “I wish there would be at least some kind of stability, some kind of permanent contract with good safety and working culture.”

Of course, there are jobs out there, especially if one is ready to go beyond Europe’s borders. However, when it comes to CRM – Crew Resource Management – the playing field shrinks and the cultural differences grow. “My son got a 3-year contract in Turkey, but it had to be renewed each year, so it was a three times 1-year contract, I would say.”No need to go any further to understand that the huge investment combined with such an uncertainty simply cannot be appealing.  “In 1989, when I started, the industry was predictable. The digitalization and the freedom brought good things (mainly for the public) but it has an unavoidable effect on safety.” And this is perhaps the greatest concern for each involved.

Yet, aviation remains the place to be for anyone who finds it irresistible not to fly, and as Renault says “it’s a lot of fun.”

What are the best memories of a captain, who flew both helicopters and large commercial jets and worked both on the Navy and on the commercial sections? “Flying with my son and sharing the cockpit with him is fantastic. Also, flying when it's dark as you’re taking off and the sun comes up, all the romantic way of looking at flying, you know.  But I relish memories from my Navy time, too: I did all those nice, challenging and sometimes forbidden stuff – looking back today, it was all great, but I don’t know if I would do it again at this age.” 

Check out our video with Renault Bosma, where he elaborates on:

Read more articles about ECA Just Culture Ambassadors:

“As long as you are doing your job, you should not be punished” – Portrait of Bert Bonke Pilot and Accident Investigator

Don’t play the blame game – Lessons from Peter Beer, Pilot & Accident investigator

“Instead of doing all the mistakes yourself, learn from someone else’s” – Portray of Johan Glantz Pilot
 

Get more information about ECA Reporting Matters Campaign here: