In the aviation industry, safety has always been the most crucial issue, with the overall goal of the International Civil Aviation Organization (ICAO) to ensure stable and safe growth and expansion of aviation in the world. With safety as a major concern, every single individual in the aviation industry has to be involved as accidents often happen as a result of an undesirable chain of events. In order to avoid a repetitive occurrence of such problems, all accidents and incidents that happen have to be reported without biases and be comprehensively documented by aviation professionals. This calls for full contribution and dedication of professionals to a safety investigation of any reported incidents. This strategy can only be achieved by developing a climate of honesty and cooperation among the aviation staff and their ability to always learn from mistakes and take appropriate remedial actions to prevent similar emergencies. A just culture should be adopted.
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However, there is a perceived trend of the authorities, who have developed a habit of initiating criminal prosecution against aviation professionals. In its turn, the tendency to incriminate stakeholders has become detrimental to aviation safety, leading to reduced willingness to properly report errors by those involved in such incidences.
This report aims at discussing various steps of adopting a just culture in the aviation industry. The right balance between the need to improve aviation safety and recognition of a judicial system, whose legitimate role is to investigate and prosecute committed crimes, without vindicating aviation professionals to such an extent that they fear giving the right information on safety issues.
In order to achieve a climate of honesty among aviation professionals, three principles have to be taken into consideration, which may enhance aviation safety. First, there has to be an appropriate determination of safeguards, which ensures that people involved in safety investigations are not punished for the actions they report. Second, protection should not be granted in cases where unacceptable behavior and gross negligence are involved. Third, improved aviation safety can only be achieved by encouraging proper and unbiased contribution to safety investigations (GAIN, 2004). This paper, therefore, discusses how to obtain the three highlighted principles of enhancing aviation safety.
Reporting of Mistakes in the Aviation Industry
The reporting system was first initiated in 1976 after TWA Flight 514 crashed into Virginia mountaintop while descending onto Dulles Airport in Washington DC. A united airline had narrowly escaped the same fate six weeks earlier. This emergency called for the establishment of an industry-wide database of safety incidences, starting the inception of ASRS (Billings, 1999). ASRS is a confidential reporting system that provides valuable data about safety incidences in the aviation industry.
A mistake or unprofessional behavior can be reported by an employee to the ASRS, which is often administered by NASA. NASA functions as an independent third party, whose mandate is to identify the reports and compile them into a database that is publicly searchable. This information is then used by the aviation industry and the national government to improve safety; it issues alerts and makes policy changes (Billings, 1999). It also communicates safety trends via newsletters to the rest of the aviation community. The employee who has reported a safety issue is granted immunity from prosecution, but if he/she is suspected of professional misconduct or negligence by an independent investigation, then the immunity is withdrawn. Immunity is often exercised once every five years.
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Reporting of mistakes and errors in the aviation industry greatly depends on cooperation and honesty of aviation professionals. These mistakes can only be avoided or reduced if the employee is assured of immunity from vindication after reporting a case, apart from those committed due to negligence (Billings, 1999). However, following increased concern over a perceived trend of the governmental authorities to initiate criminal prosecutions and trials against aviation professionals, there has been a reduction in honesty when it comes to reporting mistakes and errors. Such fear has led to an immense amount of incidences, such as accidents due to poor information reporting. This leads to cursory or substandard investigation, causing repetition of these mistakes. For aviation safety to be trustworthy, there has to be a clear unbiased indication of who should be held criminally responsible for an incidence: an employee or the entire company, and on what conditions can they be subject to punishment.
Nonetheless, the ASRS system has its shortcomings regarding the delivery of justice when it comes to error detection and provision of immunity. This has to some extent hindered the maximum achievement of safety in the industry. For instance, in 2009 February, Colgan Air Flight 3407 accidentally crashed into a house in Clarence Center in New York. The crash killed 50 people, and the pilot blamed his fatigue, which made him unable to respond to warnings. This claim provided him with immunity from any consequences, and he could not take full responsibility for his actions. It is like getting out of jail free (Billings, 1999). The ASRS system values information about safety incidences more than punishment for unprofessional behavior, and this obstructs justice to all parties.
Criminalization of Aviation Accidents
When it comes to aviation safety, criminalization of accidents has taken a different angle, and most people in the industry believe it does not make sense to criminalize nonintentional careless conduct or gross negligence. Such penalties do not belong to aviation safety investigations. However, in the past, some employees have been vindicated for falsifying records. For example, Eastern Air Lines were first accused of this misconduct in the 1990s. According to Ken Quinn, an aviation lawyer, criminalization of any aviation accident hinders cooperation among flight crews and other staff members (Crouse, 2010). Such criminalization also impedes proper investigations in any incidence that may occur since the employee involved will fear criminal prosecution that may lead to job loss.
Several people have been judged and prosecuted, depending on the kind of aviation accident, and this has impacted both the companies and employees. For instance, on November 30th, 2007, McDonnell Douglas MD-83 facility was destroyed following an accident that occurred near Isparta Airport, Turkey. In this accident, all people on board died. This aircraft had been leased to the Atlas Jet Airlines by World Focus Airlines. The managers from both airlines were sentenced to 11years in jail and 8 months on homicide negligence charges. A prison sentence of 5 years and 10 months was imposed on the maintenance director of World Focus Airlines. On the same note, two pilots were sentenced to 3 years and 6 months each for false testimony concerning the accident. In this case, the deputy director general and the director general of civil aviation faced charges of office misconduct (ASN, n.d.). They were both incarcerated for 1 year and 8 months.
In another case, a French pilot received a 6-month-sentence for causing an accident in a location called Pau in France, killing a man who was on the ground. This accident happened on Jan 25th, 2007. The Fokker, which is a 100 passenger jet of a French regional carrier, overshot the end of the runway due to un-aborted takeoff. The investigations into this incident confirmed that the accident resulted from the unavoidable loss of control due to the presence of ice contamination on the wings, in addition to a failure to consider prevailing weather conditions. Also, negligence within the French aviation community in considering the risks of ice on the ground was noted. The pilot was convicted of homicide and unintentional injuries. An extra charge of 20.000 Euros was imposed on the airline as well (ASN, n.d.). Analyzing the two cases, it becomes clear that criminal prosecution does not only have dire consequences for employees, but, depending on the type of a mistake, the airline company can be charged too, as it was the case with the French airline.
An employee has to be assured of immunity from vindication and prosecution, if he/she is expected to give clear information on what happened in an accident. This facilitates an in-depth investigation into the incidence. However, fewer occurrences of transportation accidents should not connive criminal conduct. In situations where intentional falsifying of records and violation of criminal statutes take place, one should not get a pass because these acts may have caused transportation accidents rather than any other type of accidents. In order to ensure that some mistakes do not go unpunished, all states must work towards harmonizing their criminal laws that relate to transportation with the product liability law (Crouse, 2010). Unintentional acts that cause accidents should however not be subject to criminal prosecution.
Aviation safety cannot be improved by criminal sanctions since people are not always forthcoming. Considering that human errors contribute to 85% of aviation accidents, criminal prosecution cannot change an unintentional act. Therefore, such a form of prosecution in the aviation system is not logical. Prevention and not conviction is the ultimate goal of achieving aviation security. In a nutshell, criminal prosecution in the aviation industry should not be advocated for since it impedes safety by causing the accused employees to become fearful of offering clear insights into what happened, expecting charges and prosecution (Crouse, 2010). This leads to poor investigations and an increase of aviation incidents and accidents since mistakes are not well corrected.
Concept of Just Culture
A just culture stems from a safety culture that involves just learning and reporting. Therefore, the just culture implies safety thinking, which often promotes a platform of positive attitude and commitment to excellence, resistance to complacency, and enhancement of personal accountability as well as corporate self-regulation, especially where safety of any type matters. Such a culture creates a comprehensive atmosphere of trust where stakeholders are encouraged and possibly rewarded for their willingness to provide essential information related to safety (GAIN, 2004). Thus, a ‘just’ safety culture attitude oriented towards both individuals and organizations. Unsafe activities are often suspected precursors of common accidents and related incidents in the aviation industry. They are determined by personal attitudes and a corporate style. Such acts require active identification of safety issues and a response together with appropriate actions.
The just culture enables stakeholders to learn from unsafe activities. The most outstanding goal of any aviation manager is always to promote safety during an aviation service production. Anything related to safety in the organization, including human errors, must be considered an opportunity to find ways of improving operations via learned lessons and experience feedback. A good organization with a proper safety culture considers failures and incidences as lessons that can be learned to avoid future mistakes. Such organizations always strive to ensure that any potential destructive event is appropriately reported to the right office and investigated so as to determine its root causes. Timely feedback on the findings is critical for proper actions to be taken (GAIN, 2004). If any organization wants to learn from incidences, they have to recognize and acknowledge that human errors cannot be eliminated only moderated. To manage human errors, a change of environment in which employees work must be initiated. In order to make countermeasures effective, individuals have to be willing to report their errors. This calls for an atmosphere of trust, which encourages people to provide essential safety-related information without fear of vindication.
Adapting a just culture comes with several benefits among them, for example, increased reporting of especially previously unreported events and identification of some trends that could provide insight into unrevealed matters. Lack of reporting does not mean safe operations, and similarly increased reporting is not an indicator of decreased safety. However, reporting of events brings an illumination of potential safety concerns. It is also a form of building trust where different members with an infrequent contact with policy decision making are brought together. A just culture also creates effective safety and operational management (GAIN, 2004). It is achieved with the help of enhanced organization’s effectiveness where it defines expectations from job performance and establishes clear guidelines of the consequences of deviating from the set procedures.
Once an organization shifts from a blame culture and adopts a just culture, it experiences benefits that may positively contribute to the safety of the organization where the emphasis will be laid on two crucial but not mutually exclusive concepts. These concepts include the following points: the organization should be able to understand that human errors are unavoidable, therefore, the system needs continuous monitoring and improvement to rectify them. Every stakeholder should be accountable for what they do, especially if they knowingly violate safety procedures (Westphal, 2009). To effectively and exhaustively monitor the safety of the organization’s system, an organization has to adapt the just culture. This enables the company to understand the effects brought about by the normal human errors.
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Embracing a just culture does not necessarily mean that people should not be held accountable for their errors, instead, it is all about adopting an effective way of holding someone accountable for their mistakes. In the aviation industry, when the authorities choose to punish someone for a mistake, safety cannot be achieved whatsoever. It is not the best way of helping an employee learn from their faults. However, reviewing what occurred and caused an error furthers reliability and advancement of airlines operations (Westphal, 2009). At times, a problem occurs due to some fault in the system rather that a human error and, therefore, a resolution to change the employee without rectifying the mistakes in the system will not eliminate the problem, which will still occur even with another person in charge. Thus, a just culture often works towards finding the most appropriate way of holding both the system and people accountable for any error that may occur. In most cases, the system puts employees in a tough situation and if decisions and actions are not well arrived at, things turn out badly. It is given that no one goes to work with an intention of doing something wrongly, but, unfortunately, a drift may occur during the work process. People cannot avoid mistakes and inaccuracies. Managers and executives have to decide whether they need to make changes, which will have positive impacts both on the employee and the system, with an aim of reducing errors (GAIN, 2004). Inputs and outputs have to be balanced, and a decision on how to be proactive must be made too.
Precursors of bad events are often missed events. It is important that the managers keenly examine missed events and design a system, which includes the behavioral choices that may have occurs in the event of an incidence. In a sensitive industry like aviation, the managing team should be in a position to see what influences the systems reliability and work, and they should be able to manage the two. When it comes to managing human reliability, an examination of the rate at which people make mistakes should be considered. Their qualifications, skills, knowledge, and perception of risks should also be looked into (Westphal, 2009). Management should also understand an employee’s strengths and weaknesses. An organization that runs on a just culture can distinguish three kinds of behaviors and manage them. These patterns of behavior include:
· Human error occurring when the mistake was not intended.
· At risk behavior that happens when an individual does something without knowing related risks.
· Reckless behavior, unjustified one that disregards consciousness.
Human errors and risks are the most common behaviors in the aviation industry that, to some extent, are unavoidable. As it has been said earlier, no one goes to work with an intention of making mistakes. However, this does not mean that such behaviors should be tolerated at the expense of involved dangers. These behavioral patterns can be altered by keeping employees informed and also educating them on how to avoid risky decisions. If an employee is not sure of something, they should not try it out but seek guidance on the best way to handle it (Westphal, 2009). A just culture often takes proper and informed steps when investigating an event or incidence that may have occurred. It follows a procedure of determining why something happened, what led to that event, what were the causes, and how the system was working at the time the incidence occurred. These questions assist the investigating team in determining the cause and effect relationship, explain both at-risk behavior and human error, and ascertain any procedural deviation. A just culture, therefore, is like a journey where one analyzes their outcomes, systems, choices, and tries to make appropriate improvements. A just culture is defined by embracing a commitment to values, a system design, and behavior choices. For example, the impact of reporting errors is quite positive and with such a culture employees do not fear to give clear information on what happened in an incident (Westphal, 2009). Positive outcome is possible because those who are involved are assured of fair judgment and prosecution if it is needed. This strategy, therefore, enhances safety, and it should replace the blame culture that has seen a rise of errors in the aviation industry.
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The best way to correct a mistake in any organization is to learn from it. In the aviation industry, prosecution of professionals for mistakes hinders progress and impedes security. This should not be adapted to unintended mistakes as a human error is always possible and no one is exempted from making mistakes. However, reckless and intentional errors, such as falsifying documents, should not go unpunished as this will encourage uncouth behaviors among employees. All in all, dealing with errors in a just culture has to be embraced by everybody in the aviation industries since it is the only way to assure employees of fair prosecution in the event of an incidence. This culture examines mistakes from the point of view of both the employee and the system and comes up with a clear conclusion on what necessary steps should be taken to avoid similar mistakes in the future. It should, therefore, replace the blame culture that has for a long time held the employee responsible for some mistakes that could have occurred due to faults in the system. This blame culture has hindered proper investigations of incidences since the employee feared to give clear information on what had happened. With the just culture, investigations are properly done, which enhances safety in the industry.