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"JUST CULTURE IN THE CONTEXT OF OCCURRENCE REPORTING SCHEMES"

19th April 2012

A Positive Safety Culture

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A corporate initiative on Safety Culture launched in March 2011

Recommendations

from the

Independant Safety

Review Team

SMS, pillar 1

« A positive Safety

Culture »

Flight Ops,

Trajectoire

Program, Axis n°4 :

Safety Culture

A corporate

initiative on

Safety Culture

sponsored by

the Accountable

Manager

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A new commitment to Flight Safety signed by Air France Executive Committee

Promote individual

and managerial

atttitudes that benefit

flight safety

Establish Flight

Safety as an

obligation

Right to

human error

Obligation to

transparency

Managerial policy :

neither overly punitive,

nor lax

The Executive Committee’s Commitment to Flight Safety

Flight safety is a daily obligation and must be the primary and permanent focus of every member of staff. Guaranteeing safe operations in which our customers and Company staff have total confidence is built on everyone’s personal commitment. The prevention of incidents and accidents also largely depends on the lessons learned on a daily basis from events that could affect the safety of operations. To this end, the members of the Executive Committee are personally committed to:

- Promoting feedback concerning all unusual situations, or providing positive or negative information potentially related to flight safety;

- Promoting practices at all levels allowing to build trust within the organization. These concern in particular :

o Acknowledging the right to human error, o Guaranteeing a just and fair managerial policy (neither unfairly punitive or lax), o Proceeding with a fair analysis of the organizational causes and, where appropriate,

the individual responsibilities in situations related to flight safety, o The obligation to evaluate the impact in terms of safety of any significant modification

to our processes, - Avoiding all arbitrage detrimental to flight safety, particularly facing operational, commercial or

financial issues. It is everyone’s personal responsibility to systematically communicate without delay all events or situations that will allow us to improve our safety management. This obligation does not only concern those who are in direct contact with the aircraft; everyone, whatever their profession or hierarchical level in the organization, must identify the potential impact of their decisions, actions or observations on flight safety. To encourage feedback, the members of the Executive Committee are committed to ensuring Air France does not instigate any disciplinary proceedings against a member of staff who spontaneously and promptly reports a breach in safety rules, except in cases where the failure to fulfil a duty is intentional or repeated, or brought to light by an accident. This commitment similarly applies to the people directly involved in the reported failure. Beyond this obligation to transparency, it is through the development of positive attitudes such as thoroughness, vigilance, responsible behaviour and mutual trust that everyone will contribute to the ongoing improvement of our operational safety.

* Translation – the original document is in French

*

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•Professionalism

•Compliance … and beyond

•Individual responsibility

•Positive decision making

•Trust

•Transparency

Developing a positive safety culture at both individual and corporate levels

Key Values :

Trust

•Role-model behaviours

•Unacceptable behaviours

Spontaneous

Reporting

Feeding the

SMS

(dangers,

risks)

Continuous promotion of positive behaviours

Continuous improvement of the system’s safety barriers

Th

e In

div

idu

al

Th

e A

irlin

e

Key Behaviours

Corporate

Safety

Policy

Just & Fair

Managerial practices

Transparency

(re. events and

company’s response)

Processes

(company’s ability to

integrate feedbacks)

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Defining and implementing « Just and Fair » managerial practices

The lead expert’s role

« Référent Just & Fair »

Respond to the managers‘ requests,

or solicitate those managers coming

across situations related to Flight

Safety

Help out the manager to appropriate

the " Just & fair" culture

The Manager’s role:

Make a just and fair decision :

-"Fair" regarding organizational issues,

capable to challenge yourself to potentially

draw up an efficient action plan.

- "Just" in terms of individual responsibilities

by distinguishing acceptable and

unacceptable behaviours

The « Just & Fair » process

It is an event-analysis process that goes beyond objective facts, in order to help the

manager to make a decision

This analysis must bring up the organizational factors which may have led to the event,

and then the possible personal responsibilities, and proposes actions in both fields

It is a documented approach which has proved its worth in other companies in the airline

industry ( refers to the " Just Culture" )

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Elements of the implementation plan …

1. « Flight Safety, Culture and Management » : an e-learning

module introducing the principles of Just & Fair,

introducing the Just & Fair Lead experts (Référents Just & Fair)

2. Top-down approach through management meetings : Guidance material provided to the managers’ managers to facilitate a 20

minute discussion in management meeting

Individual questionnaire answered after the meeting by all managers : « how

easy / difficult will it be in your domain to implement Just & Fair managerial

practices ? »

3. Communication events, and a

Corporate intranet Flight Safety portal.

4. Safety Culture Indicators

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7 key safety principles

Behaviours expected from every staff member

1. Consider flight safety as an obligation, fully integrated in every activity on a daily basis.

2. Practice a « just » level of individual responsibility

3. Practice transparency

4. Comply with procedures ;exceptionnaly, deviations from procedures might be required to achieve a higher degree of safety

5. Practice a level of awareness proportionate to the situation

6. When in doubt, always choose safety

7. Accept to question your own practices

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Safety Culture at Flight Ops

“This is the way we do things around here”

Encourage Rex

(reporting)

To be

informed

To be mindfull – To be

implicated

Learn from the

past – seize

opportunities-

Be flexible

ATQP

Stabilization

FOR DEC

…

Just and Fair

CIRP

ASR

LOSA

FDM

…

Safety Assesment Studies

Safefy Scoreboard

PATHOLOGICAL Who cares as long as

we’re not caught

REACTIVE Safety is important, we do

a lot every time we have

an accident

CALCULATIVE We have systems in place

to manage all hazards

PROACTIVE We work on problems

that we still find

GENERATIVE Safety is how we do

business round here

Other staff

Pilots

Focus: safety data management improvement

Flight data monitoring:

new protocol

1. « Gate keepers » joint-team settlement

2. Detection of frequency incidents per pilot

3. Ability to contact directly pilots first officers

4. Ability of the Flight data monitoring department to

provide pedagogical support to pilots

Focus: The Just and Fair process after an

incident within AF Flight Operations

Just & Fair

Analysis process Just&Fair (matrix) : to be determined

Management decision

Facts gathering

Internal inquiry process Make every effort to understand the reasons of the event, by associating all the actors. Propose recommendations

Event during pilot duty time with an impact on flight safety

Treatment by the Management

Critical Incident Response Program (CIRP) To save the crew and ensure safety of the operations

Decision to launch an enquiry Y / N

Factual report

Exchange of informations

Final report

Initial treatment regardless of eventual enquiry

Assistance Just & Fair : To make sure that the process is efficient througout the Company, and to follow the action plans taken and their results. To drive the conduct of changement among management and pilots

Exchange of informations

Peer to peer contact

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OUTCOME and CONCLUSION

1. Trust is key to improve the quality and quantity of the source of data.

2. To implement a positive safety culture takes TIME ! -Continuous efforts -Consistent Corporate communication 3. It has to be a common and shared effort: (Regulators, industry, judiciary … ) BUT don’t forget that : Culture goes beyond training and communication, it’s about

concrete action plans