Just Culture

Airlines are high-reliability organisations (HRO) evolving in an ultra-competitive and regulated environment where market differentiation is challenging (e.g., a limited option of original equipment manufacturers (OEM), routes) and thin profit margins. 

Often they are defined by their business models (i.e., legacy carrier (LC) or low-cost carrier (LCC)). 

Because the industry is in perpetual motion and is publicly visible as most airlines care about their brand image, the slightest mismatch could result in financial, operational and safety disasters. 

Development of Just Culture has been one of the most important advancements in airline safety management over the past two decades. The majority of western aviation organisations have incorporated Just Culture into their management practices, however the transition has not taken place in many other parts of the world, including in China, which is emerging as the largest aviation market globally.

This paper explores the current nature of safety management culture in Chinese airlines, and examines what impact the perception of fairness and accountability has on pilot performance in Chinese airlines. Also, how Chinese national culture affects management culture has been explored.

This research has found that blame culture is the prevalent management approach in Chinese airlines, and that introducing Just Culture practices would bring about numerous advantages compared to the current situation. This view is supported by extensive research into contemporary safety management literature.

Besides theoretical information, the research includes interviews with Chinese airline managers, and a survey that gauges the opinions of both Chinese and expatriate pilots working for Chinese airlines. The research indicates that both managers and pilots recognise the opportunity to improve the system. The negative effect the current blame-focused system has on pilot performance is clearly identified in the pilot survey.

Several recommendations on improving aviation management and practices are proposed to Chinese airlines, the regulator, and other aviation organisations. The paper concludes that Chinese aviation would greatly benefit, both in terms of safety as well as financially from the implementation of the recommendations. However, changing organisational culture is difficult and requires determination and resolute action. Recognising this difficulty, the author recommends raising awareness with all the stakeholders in Chinese aviation as the initial step towards proactive safety management and Just Culture.

The Legislative Decree No. 173/2017 sets forth the sanctions for the infringement of EC Regulation No. 216/2008. The wording of the decree, in particular of article 12 on the rules of the air, may be a threat to the long path which led to the establishment in the Italian civil aviation of a just culture, defined as the «atmosphere of trust» in which front-line operators are encouraged to provide essential safety-related information. By the analysis of the international and European regulatory framework on just culture currently in force, the paper examines the sanctions set forth by the recent Legislative Decree, highlighting its contradictions and the risk that the protection of the just culture moves backwards due to the wording of such decree, which does not differentiate between «wilful violations» or «gross negligence» and «honest mistakes».

This article is the second part of a series on air accident investigations. With reference to aircraft accident and incident investigations, and the use of results of such investigations, the article discusses the issue of the proper balance between ensuring aviation safety and executing responsibility. The possible conflicts between the realisation of both goals in the context of criminal, civil or administrative proceedings are explored. The article concentrates on just culture principles aimed at balancing safety and responsibility in aviation. This includes a discussion of EUROCONTROL heritage in this respect and of the implementation of these principles in Annex 13 to the Chicago Convention, Regulation 966/2010/EU and Polish aviation law. The analysis focuses on the precautionary goal of investigations, institutional independence and relations between safety investigations and other proceedings. It concludes with recommendations for the lawmaker.

This paper will synthesize the work of Reason, Dekker, Vaughn, Snook, Hollnagel, and justculture.org to show how wildland fire management can evolve from retributive justice (focus on punishment) to restorative
justice (making victims whole). The development and maintenance of a restorative just culture is a cornerstone to improving safety and morale at all levels of the organization.

article in Dutch.
The Academic Medical Center, Amsterdam, has started a trial to evaluate the usefulness to team debriefings of performance reports generated by a medical data recorder (MDR) in the operating room (OR). Outcome performance reports in structured debriefings in a secure, non-punitive environment are likely to heighten the level of situational awareness of OR teams. This may prevent future error. In addition, the use of video and - even more likely - use of an MDR may contribute to establishing a 'just culture' in the OR. MDRs offer a wealth of data, but only if these data are processed well do the resulting outcome reports reveal insights useful for structured debriefings. The implementation of video recordings or MDRs must be preceded by carefully addressing privacy and litigation issues relating to both OR staff and patients. In this article, we address viewpoints and discuss implementation strategy and the legal considerations involved in enabling the use of video and data registration in the OR.

Many social service agencies that provide services for the Intellectual Disability and Developmental Disability (ID/DD) employ, develop, and use non-nurses to medicate and coordinate healthcare services in their group homes. These non-nurses, Approved Medication Assistive Personnel (AMAPs), are supervised by registered nurses.
Trends in Developmental Disability Nursing show that there are increases in reportable medication errors to internal regulatory departments responsible for risk management of different agencies such as Quality Assurance/ Performance Improvement (QA/PI) departments. Occasionally, these agencies report serious medication errors to the Justice Center, the regulatory and standards enforcement division of Office of the People with Developmental Delay (OPWDD). The Quality Assurance/Performance improvement departments of these ID/DD-Agencies investigate and archive all medication errors notwithstanding the severity of the error.

This article is the third part of a series on air accident investigations. It develops on the legal status of findings of aircraft accident and incident investigations. The extent to which such findings may be binding in civil, criminal and administrative procedures is analysed. Emphasis is placed on the probative value of aircraft accident and incident investigation final reports. Further, the possible status of such reports as official documents and the consequences of such status for particular types of proceedings is discussed. Lastly, possible constraints to the use of reports which arise from general procedural rules as well as from specific provisions of air law are investigated.

This article is the first part of a series on air accident investigations. It presents a digest of international, regional and domestic sources of law concerning aircraft accident and incident investigations, and explains the relations between the discussed legal regimes. In particular, the differences between investigations in civil aviation and in state aviation are explained. This includes a presentation and study on so far unpublished provisions on accident investigations contained in international agreements concerning state aviation.

To investigate faculty and residents' perceptions of whether SimWars can serve as a meaningful instructional format for Emergency Medicine residents and to identify strategies to implement SimWars effectively in a residency training program. Methods: In this descriptive interview study, 5 facilitators, 2 contestants, and 8 observers were recruited from an Emergency Medicine residency program at a large, urban, university-based, level-I trauma center. Interview questions were created with the guidance of the social constructivism theory. Participants were interviewed individually. Themes were identified associated with responses to these questions. Results: (1) SimWars can be a meaningful instructional tool; (2) Debriefings and a well-structured rubric are essential; (3) Competition motivates participants to do their best, but can have a negative impact on them; (4) Residents expect to use the clinical skills, patient management and teamwork skills practiced in SimWars; and (5) Residents need more training on teamwork, including Team Strategies and Tools to Enhance Performance and Patient Safety™ (TeamSTEPPS). Conclusions: With its focus on competition, SimWars can be effective in residents' training when debriefings are guided by well-structured rubrics.

A segurança internacional enfrenta um ambiente de ameaças cada vez mais complexo, e a aviação civil, por possuir um papel significativo na economia global, é um alvo atrativo para atentados terroristas. À luz das Ciências Aeroespaciais, a aviação civil é parte do Poder Aeroespacial, sendo que sua proteção contribui com o esforço do Estado brasileiro para assegurar a soberania do seu próprio espaço aéreo. Nesse sentido, o presente trabalho tem o objetivo de analisar como a Gestão de Riscos prioriza as ações para a Segurança da Aviação Civil contra Atos de Interferência Ilícita (AVSEC), sendo pormenorizado pela descrição da cultura justa, análise crítica da Gestão de Riscos e proposições para o fortalecimento da ferramenta de reporte de riscos. A melhora na identificação de riscos e o desenvolvimento da chamada Cultura Justa contribuem para a efetividade deste instrumento. Para tanto, utilizam-se o conceito de Cultura Justa e a Teoria da Prática para estudar o caso no Serviço Regional de Proteção ao Voo de São Paulo. Os resultados apontam que alterações normativas em diretrizes, instruções e manual do Comando da Aeronáutica, a fim de implementar a cultura justa para a proteção à atos de interferência ilícita no Sistema de Controle do Espaço Aéreo Brasileiro, possibilitaria o aumento qualitativo e quantitativo na identificação de riscos, proporcionando vantagens à alta administração, ao efetivo operacional e à sociedade brasileira.

"Een vriendelijke dokter is een goede dokter! De mate van vriendelijkheid lijkt een meetlat die veel patiënten gebruiken om de kwaliteit van de zorg te bepalen. De meeste patiënten kunnen immers niet anders. Want hoe kan de gemiddelde patiënt nu de medische kwaliteit van de zorg vaststellen? Nee, het is vooral de vriendelijkheid en de manier van bejegening die voor de meeste patiënten de kwaliteit en de veiligheid van de zorg bepaalt." "In de zorgverlening moet het begrip complexiteit niet ondoordacht of lichtvaardig gebruikt worden. Immers zorgverlening is een (uiterst) complex proces. Wanneer bij pogingen om veiligheid te verbeteren complexiteit wordt genegeerd en men het Newtoniaanse denken laat prevaleren, dan schiet men ernstig tekort. Als de human factors benadering en de beginselen van de systeemtheorie onvoldoende aandacht krijgen dan handelen manager, medicus en zorgverlener die verbetering van veiligheid en kwaliteit in de medische zorgverlening nastreven onethisch."

Airports, like hospitals, never close and, as such, healthcare providers and aviation professionals operate under a distinctive but shared set of circumstances

As a result, long and intensive shifts are common, sleep deprivation and fatigue are widespread.

Therefore, fatigue can be defined as the decreased capability to perform mental or physical work, produced as a function of inadequate sleep, circadian disruption, or time on task

Resilience allows teams to function at their optimal capacity and skill level in times of uncertainty. The SARS-CoV-2 (COVID-19) pandemic created a perfect opportunity to study resilience culture during a time of limited healthcare team experience, protocols, and specific personal protective equipment (PPE) needed. Little is known about healthcare team resilience as a phenomenon; existing definitions and empiric referents do not capture the nature of healthcare team resilience, as the traditional focus has been placed on individual resilience. This qualitative research protocol provides the rationale and methodology to examine this phenomenon and builds a bridge between resilience engineering and individual resilience. The sample is composed of healthcare team members from the US. This research may add to the body of knowledge on resilience culture in healthcare teams during the COVID-19 pandemic. This qualitative research protocol paper outlines the rationale, objective, methods, a...

To investigate faculty and residents' perceptions of whether SimWars can serve as a meaningful instructional format for Emergency Medicine residents and to identify strategies to implement SimWars effectively in a residency training program. Methods: In this descriptive interview study, 5 facilitators, 2 contestants, and 8 observers were recruited from an Emergency Medicine residency program at a large, urban, university-based, level-I trauma center. Interview questions were created with the guidance of the social constructivism theory. Participants were interviewed individually. Themes were identified associated with responses to these questions. Results: (1) SimWars can be a meaningful instructional tool; (2) Debriefings and a well-structured rubric are essential; (3) Competition motivates participants to do their best, but can have a negative impact on them; (4) Residents expect to use the clinical skills, patient management and teamwork skills practiced in SimWars; and (5) Residents need more training on teamwork, including Team Strategies and Tools to Enhance Performance and Patient Safety™ (TeamSTEPPS). Conclusions: With its focus on competition, SimWars can be effective in residents' training when debriefings are guided by well-structured rubrics.