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endorsed by EUROCONTROL’s
Provisional Council as well as its
Permanent Commission.
The reason for this is obvious; the more
people feel that their mistakes could get
them into trouble, the less likely they are
to admit to them. This results in a
working environment in which safety
improvement becomes more difficult
because of a lack of communication
relating to those areas where there is a
known safety risk but an unwillingness to
tackle it.
Trust is paramount. Despite somewhat
disappointing progress to date, with some
States more reluctant than others to amend
their laws, there is a gradual movement
towards the creation of Just Culture
environments based upon the national
characteristics and culture of the
organisations setting them up. Patrik Peters
explains: “First of all, there are different
approaches to this topic at the moment.
There isn’t a one size fits all solution.”
This is because there are different
nationalities and, more importantly,
different mentalities to contend with. Says
Peters: “What works for a northern
European mindset might not work for a
colleague from a Mediterranean country.”
What is universal, however, is the need for
trust. The control room personnel need to
have absolute faith in the system from the
beginning. “This trust can be a fragile
commodity and it only takes one instance
in which confidentiality is broken for that
trust to be lost for an entire generation of
ATC staff,” says Peters.
That said, trust can be established and
continuously improved by providing proper
feedback and follow-up. “Staff will believe
that this is a good mechanism to evolve the
profession, working conditions and
environment. This will enhance the overall
wellbeing of control staff and atmosphere
in the control room, which in turn will
improve safety records,” says Peters.
Just Culture does not seek to change the
way an incident is reported, but to support
that system in such a way as to discourage a
culture of blame. As Peters acknowledges:
“Making mistakes is a very normal thing to
do even though it is not desirable.
Everybody makes mistakes, but as long as
they are not down to negligence or the
consumption of ‘illegal substances’ we are
better off not blaming people, but rather
trying to find out why they happen so that
they can be prevented in the future.”
Every Air Navigation Service Provider
(ANSP) has slightly different procedures for
handling an incident report. In general,
however, depending on the severity of the
incident and the state of the respective Air
Traffic Controller (ATCO), the individual
involved in the incident is relieved of
his/her position immediately and offered
Critical Incident Stress Management if this
is available. The incident is then
investigated and the incident investigator’s
team, together with the ATCO’s supervisor
and management, decide on remedial
action, which could, for example, be
retraining. It is often not possible to
maintain confidentiality in the more highprofile
incidents because other people are
usually already aware that the incident has
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taken place. The same is not the case for
voluntary incident reporting.
Voluntary incident reporting
When an ATCO wants to report a
shortcoming in procedures, traffic handling
or sector manning, for example, he may do
so using the voluntary reporting procedure.
Peters says: “Here, confidentiality is an
absolute. It is needed in order to engender
the required level of trust from the ATCOs,
which is essential to make it work.”
Therefore, it is important that the process is
managed by a set of ‘trustees’ who are
selected by the control room personnel and
not imposed on them by management.
Once a report has been submitted, it is
examined and classified according to its
priority level and severity. The identity of
the reporting staff member is stripped
from the report to make it anonymous. It
is then handed to a manager with the
necessary skills, knowledge and authority
to be able to look into the problem,
clarify exactly what it is, and then
provide feedback to the incident
reporting manager. He will then provide
feedback to the ‘Ops staff ’ in the most
appropriate manner, which could be via a
newsletter for example. Peters says:
“Should more information be needed on
　
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