Nordic “Just culture” and non-punitive occurrence reporting

The constant improvement of aviation safety is based mainly on systematic data collection and the subsequent analysis of accidents and incidents. That’s why a culture of reporting all incidents without the risk of recrimination is one of the most important measures for increasing flight safety.

There is a need to learn from accidents and incidents through safety investigations in order to take appropriate actions to prevent the repetition of such events. Also, minor occurrences need to be investigated in order to prevent faults that could lead to accidents. Statistics and analysis of aviation occurrences indicate that the primary cause of aircraft accidents and serious incidents are connected to human factors. This fact should motivate and encourage everyone to turn human weakness into strength by learning from each mistake and by reporting all incidents without the risk of recrimination. In that manner, both flight safety and the enjoyment of flight will be increased for all those who fly.

  This requirement calls for reporting systems that disclose human errors and other faults that transpire on a regular basis. It is imperative, however, to create an environment in which people are encouraged, even rewarded, for providing essential safety related information – but in which there is clarity on where the line must be drawn between acceptable and unacceptable behavior.

  The Nordic States have worked together for decades to produce such an environment within Nordic civil aviation – an environment often referred to as a ‘Just Culture.’ It is a culture in which frontline operators or others are not punished for their actions, omissions or decisions that are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated.

  A ‘no-blame’ culture, with blanket amnesty on all unsafe acts, would generate legal problems and would likely lack credibility.

What is desired, therefore, is an atmosphere of trust, where errors are reported, analyzed and then used to further optimize safety.

By seeking to obtain an environment based on a ‘Just Culture,’ the Nordic safety regulators believe that both the level of safety awareness as well as the sharing of safety related information, are improved.

  One of the cornerstones in collecting and analyzing safety-related information is a confidential and non-punitive reporting system; one which facilitates the collection and exchange of information on actual or potential safety hazards and deficiencies while contributing to the prevention of aircraft accidents as required in ICAO Annex 13, Chapter 8.

  In 2001, the Danish Parliament approved national legislation introducing mandatory, confidential and non-punitive occurrence reporting and, based on the positive experiences with this system, the Nordic States actively sought to have a similar system introduced in the European Union.

  This was accomplished two years later through European legislation on occurrence reporting in civil aviation – Directive 2003/42/EC. The Directive establishes requirements for mandatory reporting of occurrences which, if not corrected, would endanger the safety of aircraft, its occupants or any other person. The Directive has been incorporated in national legislation throughout the European Union since 2005.

  This Directive defines a detailed list of examples of safety occurrences to be reported to the competent authorities by personnel with functions within the following areas:

  • Operation of aircraft
  • Ground handling of aircraft
  • Maintenance of aircraft
  • Maintenance, repair and overhaul of air navigation facilities
  • Air Traffic Control and Flight
  • Information
  • Airport operations

To pool the safety occurrence information in Europe and overcome the problems rooted in incompatible data collection and data storage formats, the European Union introduced harmonized safety occurrence reporting requirements and developed the ECCAIRS (European Co-ordination Centre for Accident and Incident Reporting Systems) database. Iceland was the first State in Europe to fully share its data in the ECCAIRS central database with Norway joining shortly after.

  The database offers standard and flexible accident and incident data collection, representation, exchange and analysis tools. The database is compatible with ICAO’s ADREP system and supports the presentation of information in a variety of formats. Several non-European States have decided to implement ECCAIRS to take advantage of the common classifications. It is generally acknowledged within the aviation community that, without intervention, an increased number of flight operations will result in an increased number of accidents. Hence the aim of a ‘Just Culture’ and the introduction of confident and non-punitive reporting systems will contribute to further ‘fine-tune’ flight safety.

  The European Commission proposed in 2012 an ambitious and comprehensive set of new rules in a proposal for a regulation on occurrence reporting - and the ambition is to move from a principally reactive towards a more proactive and evidence based aviation safety system. This proposal is supported by the Nordic States. It is expected that this proposal will contribute to avoid aircraft accidents to occur and therefore better protect air passengers in the European Union and beyond. In addition, the proposal is expected to bring economic benefits to the whole aviation community.