The Just Policy for Maintenance Errors and Violations incorporates the principles of a just culture into how M&E manages maintenance-related errors, violations and incidents, as well as the employees involved. A just culture, defined by the firm Outcome Engineering, LLC, is a “values supportive system of shared accountability where the organization is accountable for the systems that are designed and for responding to the behaviors of their employees in a fair and just manner. Employees, in turn, are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.” A just culture will place less focus on errors, events or outcomes and more focus on risk, system design and managing quality behavioral choices.
Background
The philosophy behind a just culture has been around since the mid 1990’s originating with James Reason and Sydney Dekker. Over the years, the importance of a just culture and its principles have worked its way into aviation regulations in Europe, Canada and Australia. Recently, the FAA has begun encouraging domestic carriers to consider implementing the principles of a just culture for safety in their risk management processes. The upcoming Safety Management System (SMS) regulation, currently in Notice of Proposed Rulemaking (NPRM) stage, will include language requiring a Part 121 carrier to consider a just culture to be a critical and foundational element of an effective SMS.
Outcome Engineering, LLC, has taken the early studies focused on a just culture and applied principles of engineering, human factors and the law in order to provide a tool that allows a Safety Champion to easily identify system deficiencies and assess the quality of choices made by individuals. This tool, called the Just Culture AlgorithmTM, and its associated definitions and training have been used within the M&E ASAP program for the last two years with great success. Primarily, it provides a standard process for evaluating errors or events using the same criteria, regardless of the outcome. It also clearly defines where “the line is drawn” that distinguishes reckless behavior from human errors and at-risk behavior and limits the action taken against an employee in a fair and consistent manner.
Intended Purpose of the Just Policy
Recognizing the benefits that applying the just culture philosophy has brought to ASAP, M&E has incorporated the same principles and tools into the management of maintenance errors and violations throughout M&E. The Just Policy for Maintenance Errors and Violations states M&E’s commitment to the core just culture principles:
- Recognition that not every system is perfect, to err is human, to drift from what we know to be safe or compliant is human and that risk is everywhere.
- Most interested in learning as much as possible after an error or event in order to understand risk at the individual and the organizational level.
- Willing to investigate, learn from our mistakes and share what we have learned.
- Determined to balance accountability with justice.
The Just Culture Algorithm™, applied by the qualified Compliance Manager/Specialist or ASAP ERC, provides a process for allocating responsibility – to identify what the system caused and what the human component caused. It then clearly defines when it is appropriate to support the employee, to coach the employee or, in rare cases, when to take disciplinary action.
The Just Policy for Maintenance Errors and Violations is based on those core beliefs and is designed to apply realistic expectations and common sense in order to achieve better outcomes. In order to do this, the Just Policy will incorporate the MEAA investigation tool as well as the Just Culture Algorithm™ into maintenance-related errors and violations. To ensure quality investigations and consistent application of the just culture principles, the Just Policy places the ownership of the MEAA and Just Culture Algorithm™ tools on the neutral, trained and qualified Compliance Manager/Specialists within the Director of Maintenance organization or the ASAP Event Review Committee, for events or errors reported to ASAP. Any conclusions of reckless behavior, outside of ASAP, will also require a joint ratification by the Director of Maintenance (DOM) and the TWU Safety of Flight and Compliance Coordinator. This ratification is intended to ensure that the Just Culture AlgorithmTM and principles are applied appropriately and consistently.
The DOM, Pete Sirucek, is leading the implementation of the Just Policy for Maintenance Errors and Violations as well as directing proper training and communications for all of M&E. Pete and his TWU counterpart, Brad Brugger, along with representatives from Human Resources and M&E Communications have conducted road shows explaining the purpose of the Just Policy to MIA, LAX, TUL and DFW. Plans are in work to visit ORD, JFK and AFW in the near future. M&E Training has developed a stand-up Just Policy training course that will become a required training course for all M&E Management/Supervision as well as TWU Leadership. M&E Training plans to have beta-testing of the newly developed course scheduled for mid-July.
Brief definitions
Just Policy Flowchart – the visual flow of the Cooperative Safety Investigation process described in the Just Policy.
Just Culture Algorithm™ – the decision process for assessing the quality of behavioral choices and duty breaches. The algorithm is a product of Outcome Engineering, LLC.
Safety Management System (SMS) – an organization-wide approach to managing safety risk and assuring the effectiveness of safety risk controls. Refer to Advisory Circular 120-92A or NPRM Docket Number FAA-2009-0671.
Safety Champion – an employee trained and certified in just culture by Outcome Engineering, LLC.
Just Culture – describes an organization whose culture at all levels is focused learning, fairness and consistency, safe system design and making/managing quality choices.
Just Policy – the AA M&E policy that states the M&E commitment to enhancing our safety culture and dictates actions taken to properly, effectively and consistently respond to maintenance errors and violations by applying the principles of a just culture into the employee management and investigative processes.