National Transportation Safety Board
To 19th FAA/ATA International Symposium
on Human Factors in Maintenance and Ramp Safety
September 6, 2007
I am very pleased to participate in this panel discussion on Voluntary Reporting and Just Culture. I have a great deal of interest in each of these topics and believe they are necessary components of safety culture.
Aristotle wrote some 2300 years ago: “All men by nature desire knowledge.” These words are particularly true in the aviation business. After all, each of us desires knowledge about topics such as the profitability or competitiveness of our company, our-time performance, our ramp safety statistics, parts reliability and ultimately, our success.
But as a friend once said it, “You don’t know what you don’t know.” Although not as profound as Aristotle’s words, these words have their own wisdom.
You may believe that you are aware of everything you need to know, but how can you be certain? For expanding your knowledge of safety issues, a company has dozens, perhaps hundreds or thousands of knowledge resources – employees. Employees are the eyes and ears of the operation.
I equate employees as being like the sensor probes located strategically located throughout an aircraft engine, able to signal the health of that engine. Employees are located through out your company, and they can tell us valuable information about our system’s strengths and weaknesses.
But, we need to be able to appeal to those people. Most employees are willing – even eager – to report their observations and information about safety.
In order for them to do that, they must be confident that they won’t be punished or ridiculed for proving such information.
We need to establish a climate to encourage employees to participate in expanding the knowledge base. And, I think that is why it is important that we have voluntary reporting systems.
By collecting and analyzing incident reports, an organization can better understand the specific problems encountered by employees. Armed with this knowledge, they can create basic solutions instead of short-term fixes that only hide the real problems.
I saw the benefits of incident reporting systems when I worked in an airline with some 40,000 employees, and I saw it work when I was running a corporate flight department with four additional employees. So, the point is that a voluntary reporting system can work with four employees, or 40,000 employees.
But, we also need a “Just Culture.” Just Culture is a term that is bantered about these days, but what is it?
The March 2005 Flight Safety Digest describes just culture as, “An atmosphere of trust in which people are encouraged (even rewarded) for providing safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. “
Someone recently asked how we can hold people accountable in a non-punitive culture. Well, it is important not to confuse non-punitive with accountability. People must remain accountable for their actions, even in a non-punitive environment.
I look forward to hearing the discussion about these most important topics.