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The Legal Definition of ‘Just Culture’ in Aviation

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The Just Culture Principles in Aviation Law

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Abstract

The concept of ‘just culture’—elaborated, as we have seen, by James Reason in the 1990s and subsequently developed by other authors and extended to many sectors—has been legally recognized in aviation legislation at international, European and national level.

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Notes

  1. 1.

    Licu et al. (2013), p. 14 ff.

  2. 2.

    So ‘Just culture’, in https://www.skybrary.aero/index.php/Just_Culture.

  3. 3.

    GAIN, A Roadmap to a Just Culture: Enhancing the Safety Environment, cited above, p. 4 ff.

  4. 4.

    Orasanu (1993), p. 137 ff.; Weiner et al. (1993); Murray (1997), 7, p. 83 ff.; Hudson (2002), p. 74.

  5. 5.

    From GAIN, A Roadmap to a Just Culture, cited above, IX.

  6. 6.

    Giannini (1952), p. 579 ff.; Monaco (1981), p. 403; Sciolla Lagrange (1990), p. 1 ff.

  7. 7.

    ICAO Assembly 36th Session, Montréal, 18–28 September 2007.

  8. 8.

    ICAO Working Paper Assembly – 36th Session, Technical Commission, A36-WP/232 TE/76 of 18 September 2007, Agenda Item 28 entitled “Implementation of a ‘just culture’ concept”, supra.

  9. 9.

    See Working Paper of I CAO Assembly, 36th Session, Technical Commission, A36-WP/232, TE/76, supra, p. 1.

  10. 10.

    A36-7 ICAO Global Planning for Safety and Efficiency, in Resolutions adopted by the Assembly, Assembly – 36th Session, Montréal, 18–28 September 2007, provisional edition, September 2007.

  11. 11.

    Resolution A36-7, ICAO Global Planning for Safeguard Efficiency, Appendix A (Global Aviation Safety Plan).

  12. 12.

    O’Leary and Chappel (1997), p. 11 ff.

  13. 13.

    See Vaughan (1999), p. 271 ff.; Cohen-Charash and Spector (2001), p. 278 ff.

  14. 14.

    ICAO Working Paper Assembly – 36th Session, Technical Commission, A36-WP/232 TE/76 of 18 September 2007, Agenda Item 28 entitled “Implementation of a ‘just culture’ concept”, presented by Portugal, on behalf of the European Community and its Member States, by the other States Members of the European Civil Aviation Conference and by Eurocontrol, par. 1 (development of an adequate “just culture” concept), para. 1.4, 2 and Appendix letter a), 4.

  15. 15.

    International organization established by Convention relating to Co-operation for the Safety of Air Navigation of 13 December 1960, as amended by the amending Protocol of 12 February 1981 (amended Convention) and by the Brussels Protocol of 27 June 1997 (revised Convention), consolidating the Eurocontrol International Convention relating to Co-operation for the Safety of Air Navigation of 13 December 1960. See Sardella (1995), p. 12 ff.; Schwenk and Schwenk (1998), p. 129; Spadoni (2001), p. 259 ff.; Trovò (2008), p. 163 ff.

  16. 16.

    International organization established by Convention relating to Co-operation for the Safety of Air Navigation of 13 December 1960, as amended by the amending Protocol of 12 February 1981 (amended Convention) and by the Brussels Protocol of 27 June 1997 (revised Convention), consolidating the Eurocontrol International Convention relating to Co-operation for the Safety of Air Navigation of 13 December 1960; Sardella (1995), p. 12 ff.; Schwenk and Schwenk (1998), p. 129; Spadoni (2001), p. 259 ff.; Trovò (2008), p. 163 ff.

  17. 17.

    See Licu and van Dam (2013), p. 18 ff. and Licu and van Dam (2014), p. 55 ff.

  18. 18.

    See Starrantino and Finocchiaro (2014), p. 27.

  19. 19.

    You can find a graphic representation of these differences in SwissATCA, Just Culture Manual for ATCO, ANSE & ATSEP, Behavior after an incident and further proceedings, p. 8, in https://skybrary.aero/bookshelf/books/4222.pdf. See Muchinsky (1997); Moorman and Pipers (2002).

  20. 20.

    Eurocontrol, ESARR Advisory Material/Guidance Document (EAM 2/GUI 6) of 31 March 2006, ed. 1, p. 17. This guidance material is derived from the research of existing best practices and in particular from the conclusions and recommendations of Eurocontrol’s “Safety Data Reporting and Data Flow Task Force” report. This document is intended to be supporting guidance for anyone involved in implementing ESARR 2, especially when encountering difficulty in introducing reporting and assessment systems. ESARR is acronym for Eurocontrol Safety Regulatory Requirements. These requirements contain technical rules on safety, which need be implemented in the European Union or national regulatory framework of its Member States. ESARR 2 is entitled “Reporting and Assessment of Safety Occurrences in ATM”, edition 3, 2 December 2009. It defines a list of ATM-related occurrences which shall, as a minimum, be reported and assessed by States (Appendix A), defines the minimum appropriate safety data which shall be collected and reported to Eurocontrol by States, expressed in terms of high-level safety indicators (Appendix B) and includes a glossary of terms with harmonised definitions (Appendix C). The majority of ESARR 2 requirements has been transposed into European Community Law by Directive 94/56/EC and Regulation (EU) No. 376/2014 (see below). See Nastro (1993), p. 407 f.; Cook (2016), para. 8.3.2 (Safety, Transparency and ‘Just Culture’); Brooker (2007), p. 3 ff.; Van Antwerpen (2009), p. 83; Pellegrino (2009), p. 216, Pellegrino (2012, 2014); Bieder and Bourrier (2017), para. 1 ff.

  21. 21.

    So ICAO Safety Management Manual (SMM) Doc 9859 AN/474, Third Edition, 2013, 2.5, pp. 2–8.

  22. 22.

    A33-17 “Non-disclosure of certain accident and incident records”, in Resolutions adopted at the 33rd session of the Assembly, provisional edition, 2001, p. 69.

  23. 23.

    A35-17 “Protecting information from safety data collection and processing systems in order to improve aviation safety”, Resolutions adopted by the Assembly, provisional edition, October 2004, p. 71.

  24. 24.

    See Espinola et al. (2005), p. 26.

  25. 25.

    Entitled “Legal guidance for the protection of information from safety data collection and processing systems”, then transposed in Attachment B to ICAO Annex 19, ATT B-1, see below.

  26. 26.

    ICAO General Assembly, 36th Session, Montréal, 18–28 September 2007.

  27. 27.

    AMC/MA/Accident Investigation and Prevention (AIG) Divisional Meeting, 13–18 October 2008, Montréal, Canada, that, inter alia, highlighted the absence of a voluntary reporting system and the absence of safety data analysis by the State aviation authorities. See Working paper AIG/08-WP/20 of 25 June 2008.

  28. 28.

    See the Working paper HLSC 2010-WP/8, 31 March 2010, of the High-Level Safety Conference 2010, Montréal, 29 March–1 April 2010, on the theme “Towards the proactive management of safety”, topic “Implementing new safety management process”.

  29. 29.

    In its final report the SIPTF recommended close cooperation between safety (in particular, just culture) and justice. See, in particular, SIPTF fourth Meeting on Just Culture, Montréal, 21–25 January 2013, presented by Roderick van Dam, SIPTF/4-IP/2 of 17 January 2013.

  30. 30.

    Published in Resolutions adopted by the Assembly, November 2010 (provisional edition).

  31. 31.

    Published in Resolutions adopted by the Assembly, November 2010 (provisional edition).

  32. 32.

    ICAO General Assembly 37th session, Montréal, 28 September–8 October 2010 resolutions A37-2 (Non-disclosure of certain accident and incident records) and A37-3 (Protecting information from safety data collection and processing system in order to improve aviation safety), published on November 2010 (provisional edition).

  33. 33.

    See Licu and van Dam (2013), p. 18 ff. and Licu and van Dam (2014), p. 55 ff.

  34. 34.

    As follows: “a culture in which front-line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence willful violations and destructive acts are not tolerated”.

  35. 35.

    Article 5(3.2): “States should extend the protection referred to in 5.3.1 to safety data captured by, and safety information derived from, mandatory safety reporting system and related sources”.

  36. 36.

    Defined as “any specification for physical characteristics, configuration, material, performance, personnel or procedure, the uniform application of which is recognised as desirable in the interest of safety, regularity or efficiency of international air navigation, and to which Contracting States should endeavour to conform in accordance with the Convention” (so ICAO Assembly Resolution A36-13, Appendix A. ICAO Doc 9902, Assembly Resolutions in force as of 28 September 2007, in http://www.icao.int/icaonet/dcs/9902/index.html.

  37. 37.

    Chapter I of the ICAO Annex 19. In addition, the ICAO “Universal Safety Oversight Audit Programme Continuous Monitoring Manual” contains the following similar definition of safety: “The state in which the possibility of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management”. See Di Renzo (2015), p. 155 ff.; Di Carlo (2015), p. 203 ff.; Guarrera (2015), p. 171 ff.; Bernabei and Barbafina (2015), p. 163 ff.

  38. 38.

    ICAO General Assembly 37th session, Montréal, 24 September–4 October 2013.

  39. 39.

    Standards and Recommended Practices (SARPs) are technical specifications adopted by the Council of ICAO in order to achieve “the highest practicable degree of uniformity in regulations, standards, procedures and organization in relation to aircraft, personnel, airways and auxiliary services in all matters in which such uniformity will facilitate and improve air navigation” (Article 37 of the Chicago Convention).

  40. 40.

    Licu et al. (2013), p. 15.

  41. 41.

    See ICAO Assembly – 38th session, Technical Commission, Draft text for the Report on Agenda Item 27, A38-WP/377 TE/167 of 26 September 2013, Article 3, p. 27-9, that supersedes Resolution A37-3.

  42. 42.

    Doc 9859 AN/474, Third Edition, 2013.

  43. 43.

    The Second High-level Safety Conference (HLSC2015) held from 2 to 5 February 2015 at ICAO Headquarter, in Montréal, Canada.

  44. 44.

    So Gilberto Lopez Meyer, IATA Senior President, Safety and Flight Operations. At the same Conference he stressed: “It is only natural that people and organizations would be less willing to report their errors and other safety issues if they are afraid of punishment or even prosecution”.

  45. 45.

    https://ec.europa.eu/transport/sites/transport/files/modes/air/events/doc/2015-10-01-just-culture/declaration.pdf.

  46. 46.

    “The safety management SARPs are intended to assist States in managing aviation safety risks, in coordination with their Service Providers. Given the increasing complexity of the global air transportation system and its interrelated aviation activities required to assure the safe operation of aircraft, the safety management provisions support the continued evolution of a proactive strategy to improve safety performance. The foundation of this proactive safety strategy is based on the implementation of a State safety programme (SSP) that systematically addresses safety risks, in agreement with the implementation of the safety management systems (SMS) by the service providers” (so www.icao.int/safety/safetymanagement/pages/sarps.aspx).

  47. 47.

    The second edition of Annex 19 is comprised of the following: an upgrade of State Safety Programme (SSP) provisions; an enhancement of the Safety Management System (SMS) provisions; an upgrade of provisions for the protection of safety data, safety information and related sources.

  48. 48.

    ICAO Working Paper, Assembly – 39th Session. Technical Commission ‘Agenda Item 36: Aviation safety and air navigation implementation support “Improving Just Culture” (presented by the Civil Air Navigation Services Organisation CANSO), A39-WP193 TE/73 of 25 August 2016. See Antonini and Franchi (2005).

  49. 49.

    McDonald et al. (2000), p. 151 ff. see; Corrigan (2003).

  50. 50.

    Reason (1997), p. 195. See also Harris (2013), p. 91 ff.

  51. 51.

    ‘First Report on the implementation of the Single Sky Legislation: achievements and the way forward’: Communication COM (2007) 845 final, Brussels, 20 December 2007. This report contains an evaluation of the results achieved in implementing the Single Sky legislation, including information about developments in the sector, in the light of the original objectives and with a view to future needs for future development of the SES.

  52. 52.

    Stadler (2009), p. 267.

  53. 53.

    See Valente (2005), p. 203 ff.; Masala and Rosafio (2006); Vincenzi (2010), p. 316 ff.; Calleja Crespo and Mendes de Leon (2011); Trovò (2011), p. 24 ff.; Petrick-Felber (2014), p. 12 ff.; Cook (2016), para. 8.3.2 (Safety, Transparency and ‘Just Culture’).

  54. 54.

    Regulation (EC) No. 549/2004 of the European Parliament and of the Council of the 10th March 2004 laying down the framework for the creation of the Single European Sky (SES) (O.J. L 96 of 31 March 2004). For a commentary, see Turco Bulgherini (2009), p. 338; Rizzo (2006), p. 407; Xerri (2012), p. 67 ff.

  55. 55.

    Recommendation No. 8 of the High Level Group (HLG), contained in the Annex to Communication COM (207)845 final of 20 December 2007, cited above.

  56. 56.

    Regulation (EC) No. 216/2008 of the European Parliament and of the Council of 20 February 2008 on common rules in the field of civil aviation and establishing a European Aviation Agency and repealing Council Directive 91/670/EEC, Regulation (EC) No. 1592/2002 and Directive 2004/36/EC (O.J. L 79 of 19 March 2008). The scope of this Regulation, initially limited to airworthiness, was then extended to the flight operations and subsequently to airport safety and to air traffic management and control systems. On December 2015 a proposal for a Regulation of the European Parliament and of the Council on common rules in the field of civil aviation and establishing a European Union Aviation Safety Agency and repealing Regulation (EC) No. 216/2008 has been presented by the European Commission. See also Regulation (EC) No. 1108/2009 of the European Parliament and of the Council of 21 October 2009 amending Regulation (EC) No. 216/2008 in the field of aerodromes, air traffic management and air navigation services and repealing Directive 2006/23/EC (O.J. L 309 of 24 November 2009). For a commentary, see Coman-Kund (2018), notes 57–58; Cassatella (2017), p. 25.

  57. 57.

    Commission Regulation (EU) No. 691/2010 of 29 July 2010 “laying down a performance scheme for air navigation services and network functions and amending Regulation (EC) No. 2096/2005 laying down common requirements for the provision of air navigation services” (O.J. L 201 3 August 2010). It has been updated by Commission Implementing Regulation (EU) No. 390/2013 of 3 May 2013, laying down a performance scheme for air navigation services and network functions (O.J. L 128 of 9 May 2013). For a commentary see Calleja Crespo and Mendes de Leon (2011), p. 281; Rossi dal Pozzo (2014), p. 22; Togan (2016), p. 224. For critical considerations about this definition, see Vernizzi (2017), p. 266 f.

  58. 58.

    The establishment of these schemes derives from the so-called “Framework Regulation”, mentioned above.

  59. 59.

    The other two KPIs are: effectiveness of Safety Management and application of the severity classification of the Risk Analysis Tool to Separation Minima Infringements. For safety culture indicators, applied in the domain of nuclear safety, see Reiman and Pietikäinen (2010).To pave the way forward in establishing a set of KPIs for Safety in ATM, Eurocontrol established a ‘Safety Data Reporting and Data Flow Task Force’ (SAFREP).

  60. 60.

    According to the KPI definition contained in Article 2, letter d), of the Regulation No. 691/2010.

  61. 61.

    A Functional Airspace Block (FAB) is defined in the Single European Sky legislative package namely Regulation (EC) No. 1070/2009 of 21 October 2009 (O.J. L 300 of 14 November 2009) amending Regulation (EC) No. 549/2004 (Framework Regulation), as an airspace block based on operational requirements and established regardless of State boundaries, where the provision of air navigation services and related functions is optimized through enhanced cooperation among air navigation service providers (ANSPs) or, when appropriate, an integrated provider, always in a performance-driven perspective. See Trovò (2011), p. 24 ff.; Bufo (2012), p. 165 f.

  62. 62.

    Annex 1, Section 2, “For national or Functional Airspace Block (FAB) target setting”, letter c).

  63. 63.

    See Vincenzi (2010), p. 310 ff.; Xerri (2012), p. 67 ff.; Tytgat (2012), p. 93 ff.; Preti (2012), p. 113 ff.

  64. 64.

    The other two indicators specified in Regulation No. 1216/2011 (point 2) are: the effectiveness of safety management and the application of severity assessment of the Risk Analysis Tool.

  65. 65.

    Commission Implementing Regulation (EU) No. 1216/2011 amending Commission Regulation (EU) No. 691/2010 laying down a performance scheme for air navigation services and network functions (O.J. L 310 of 25 November 2011, 3).

  66. 66.

    Hudson (2009), 47, p. 483 ff.

  67. 67.

    Randazzo (2004), p. 847 ff.; Giemulla and Weber (2011), p. 321 f.; Marino (2013), p. 45 ff. See also European Flight and Aviation Safety Regulations Handbook, vol. I, System, procedures and important regulations, USA International Business Publications, Washington, 2009, 34; Pifisterer (2017), p. 282 ff.

  68. 68.

    With the aim of developing these safety indicators, documents such as EASA Safety Plan and Eurocontrol’s Risk Analysis Tool and Safety Framework Maturity Survey should be taken into account.

  69. 69.

    Regulation (EU) No. 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC (O.J. L 295 12/11/2010, 35). For a commentary, see Franchi (2012), p. 41 ff.

  70. 70.

    See Michaelides-Mateou and Mateou (2014), p. 271 ff.; Baumgartner and Schorer (2017), p. 3.

  71. 71.

    See Dekker (2012), p XI f. See also Lerner and Tetlock (1999), p. 255 ff.

  72. 72.

    De Franchis (1985), p. 1402.

  73. 73.

    For a definition see Roughton and Mercurio (2002), p. 57; Sharpe (2015), p. 185 ff.; Castellani (2015), p. 80.

  74. 74.

    According to the ICAO definition, Safety Management System (SMS) is “a systematic approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures” (Doc 9859, AN/474, Safety Management Manual (SMM), third edition, 2013, xii, Definitions). According to the Eurocontrol definition, Safety Management System (SMS) is “a systematic and explicit approach defining the activities by which safety management is undertaken by an organisation in order to achieve acceptable or tolerable safety” (ESARR 3, Use of Safety Management Systems by ATM Service Providers, edition 1, Bruxelles, 17 July 2000, Appendix A, Glossary - Terms and Definitions, 16). See Ludwig (2009), Stolzer et al. (2011) and Stolzer and Goglia (2015).

  75. 75.

    So Taviano (2018), p. 253 f.

  76. 76.

    Dekker and Breakey (2016), p. 187 ff.

  77. 77.

    Ulfvengren and Corrigan (2015), p. 219 ff.

  78. 78.

    So Koivu (2013), p. 66.

  79. 79.

    Ibid.

  80. 80.

    Petschonek (2011); Marchetti (2017).

  81. 81.

    Diederiks-Verschoor and Butler (2006), p. 17 f.

  82. 82.

    Legislative Decree No. 66 of 25 February 1999 “Establishment of the National Agency for the Safety of Flight and amendments to the navigation code, pursuant to Council Directive 94/56/EC of 21 November 1994” (G.U. No. 67 of 22 March 1999). For a commentary Franchi (2000), p. 595 ff.; Pellegrino (2007), p. 333 ff.

  83. 83.

    Legislative Decree No. 213 of 2 May 2006 “Implementation of Directive 2003/42/EC on occurrence reporting in civil aviation” (G.U. No. 137 of 15 June 2006). For a commentary, see Franchi (2006), p. 137 ff.; Pellegrino (2007), p. 390 ff.

  84. 84.

    Repealed by Article 23 of Regulation (EU) No. 376/2014.

  85. 85.

    Authority created by the Italian Legislative Decree No. 66/99, mentioned above. For a commentary see Franchi (2000), p. 595 ff.

  86. 86.

    ENAC GEN-01B Circular on Mandatory Occurrence Reporting System eE-MOR, General Series, of 11 April 2011, paragraph 6, in https://www.enac.gov.it/ContentManagement/information/P2004690470/GEN_01B_accessible.pdf.

  87. 87.

    See IFATCA (International Federation of Air Traffic Controller’s Association), Technical & Professional Manual, The permanent record of the Federation’s Technical & Professional Policies (2016), Montreal (Canada), LM 11.2.1 (Just Culture, Trust and Mutual Respect), p. 4248.

  88. 88.

    IFATCA unites the professional associations of air traffic controllers from around the world. See European Union, European Flight and Aviation Safety Regulations Handbook, System, procedures and Important Regulations, vol. 1, International Business Publications, Washington, USA, 2009, pp. 84 f.

  89. 89.

    ENAC, State Safety Programme – Italy, edition 3, February 2017.

  90. 90.

    Established on 25 July 1997 by Legislative Decree No. 250 of 25 July 1997 (G.U. No. 177 of 31 July 1997) as the National Authority committed to oversee the technical regulation, the surveillance and the control in the civil aviation field.

  91. 91.

    For the definition of ‘just culture’ (“a culture in which front line operators or others are not punished for actions, omissions or decisions taken by negligence, willful violations and destructive acts are not tolerated”), see ENAC, State Safety Programme – Italy, edition 3, February 2017, p. 7.

  92. 92.

    See the definition of ‘safety policy’ in ENAC, State Safety Programme – Italy, edition 3, February 2017, p. 8 and lett. j), p. 9.

  93. 93.

    Furnham (1997).

  94. 94.

    Ruitenberg (2002), p. 22 ff.; Rizzo (2009); Dekker (2010b), p. 31 ff.

  95. 95.

    Helmereich and Clyton Foushee (1993), p. 3 ff.; Hobbs (1997); Gaur (2005), p. 503 ff; Harris (2011). See also Fanara (2000); La Torre et al. (2006); Busti et al. (2017).

  96. 96.

    Dovere (2016), p. 1023 ff.

  97. 97.

    Reason (1997), p. 195.

  98. 98.

    Gibb et al. (2016), p. 4.

  99. 99.

    See Dekker (2010a), p. 275 ff.

  100. 100.

    See Working Paper of ICAO Assembly, 36th Session, Technical Commission, A36-WP/232, TE/76, 18 September 2007, para. 1.1, 2.

  101. 101.

    See Working Paper of ICAO Assembly, 36th Session, Technical Commission, A36-WP/232, cited above, 1.2, p. 2.

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    Francesca Pellegrino

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Pellegrino, F. (2019). The Legal Definition of ‘Just Culture’ in Aviation. In: The Just Culture Principles in Aviation Law. Legal Studies in International, European and Comparative Criminal Law, vol 3. Springer, Cham. https://doi.org/10.1007/978-3-030-23178-1_2

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