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JUSTICE IN A JUST CULTURE
FAIL ING TO FOLLOW STANDARD OPERAT ING PROCEDURES
FOUR MONTHS EARL IER
CO P ILOT REPORT AND DISMISSAL
Written Report
Engine Torque Anomalies
Full Power Takeoff from the ship
Nose-up manuevers upon return to base
E-mail Correspondence
Dismissal
GORL IN v s . EMPLOYER
“Unjust, harsh and unreasonable”
“No basis for serious misconduct”
“Natural justice denied”
DECIS ION
Rationale lacked specificity
Procedure “severely flawed”
No serious misconduct
Torque anomalies – judgment
Full power takeoff – no policy
Nose-up landing – not outside safety
parameter
“BLATANTLY FLAWED AND UNJUST”
Contacting co-pilot not Gorlin
Additional issues beyond report
Not allowed to challenge copilot’s written report
A BALANCING ACT
Open Reporting Culture Individual Accountability
JUST CULTURE
Encourage open reporting by not punishing
”honest errors”
Accountability for wilful violations or gross
negligence
THORNY QUEST IONS
• Where do you draw the line?
• How is the decision made?
• Who decides?
• What opportunity should the individual be accorded?
NATURAL JUST ICE
NATURAL JUST ICE
• Standards of Conduct
• Fact Finding
• Decision Maker
• Hearing
STANDARDS OF CONDUCT
“
J U S T C U L T U R E
EU Regulation 376/2014
”A culture in which front-line operators or other persons are not punished
for actions, omissions or decisions taken by them that are commensurate
with their experience and training, but in which gross negligence, wilful
violations and destructive acts are not tolerated”
L INE DRAWING
ORDINARY NEGLIGENCE WILFUL MISCONDUCT * GROSS NEGLIGENCE
WILFUL
”Notoriously, slippery term”
“A peculiar, chameleon-like quality”
Intent to act or mere knowledge sufficient?
FAILURE TO CONT INUOUSLY MONITOR INSTRUMENTS
Thai Airways – Nepal (CFIT)
Fixated on flap malfunction = wilful misconduct
KAL 007 – Soviet airspace shoot-down
After five hours – strayed 360 miles off course = wilful misconduct
Dorton (CFIT)
Late let-down due to navigation errors but monitoring = NOT wilful misconduct
Discipline ?
Intentional violation of a safety rule
Engaging in intentional conduct that
coincidentally violates a safety rule?
AMBIGUOUS APPL ICAT ION
W I L F U L M I S C O N D U C T
“ The meat slicer must be unplugged
before cleaning”
ONE POSS IBLE TEST? – WILFUL V IOLAT ION OF A SAFETY RULE
Employee knew the rule existed
Understood the safety consequences of violating the rule
Deliberately chose to violate the rule
Choice was unreasonable under the circumstances
Source: 99 C.J.S. Workers' Compensation § 593
GROSS NEGL IGENCE
Absence of Slight Care Reckless No reasonable care
Gross Negligence ? Gross Negligence ?
ELUS IVE TERMS – BLURRY D IST INCT IONS
wilful - intentional – knowingly - reckless
RESOLVING AMBIGUITY
CONTEXT
FACT F INDING
I N V E S T I G A T I V E C O M P E T E N C E
Technical expertise
Research skills
Critical thinking and problem solving ability
Causal analysis
Interviewing
HEARSAY – INHERENTLY UNREL IABLE
Problems
Memory
Perception
Internal Bias
Fact?
EYEWITNESS STATEMENTS - UNREL IABLE?
Memory ≠ Tape Recorder
Impact Factors
Lighting
Distance
Stress
Observer’s Age
Time Lapse
Source: www.innocenceproject.org/understand/Eyewitness-Misidentification.php
CONFL ICT ING EVIDENCE
Corroboration
Credibility
Bias
Conflicts of Interest
Prior statement consistency
DECIS IONMAKERS & FA IRNESS
THE DECIS IONMAKER
Temperament
Technical Competence
Bias/ Conflicts of Interest
Communication Skills
DECIS IONS
Well reasoned
Facts not speculation or conjecture
Specific not general
FAIRNESS
Notice
Opportunity
Aggravating – Mitigating Factors
JUST ICE
Well-defined and understood standards of conduct
Understand context through quality fact-finding
Inherently weak: hearsay, eyewitness statements
Resolving evidentiary conflicts
Unbiased, impartial decision maker
Fairness – due process
Notice
Opportunity to be heard
Decisions based on a well-reasoned rationale
JUSTICE IN A JUST CULTURE
Peter N. Stein
69th International Air Safety Summit
Flight Safety Foundation
Dubai, UAE
November 14-16, 2016
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