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Just Culture in Traditional Aviation and its Integration into the Drone Industry

Published: 25 July 2024

Introduction

For this article, I have been fortunate enough to team up with, and get some insights from, Joe Hattley, a former Australian Transport Safety Bureau (ATSB) senior manager and experienced accident investigator of some 24 years, member of the International Society of Air Safety Investigators, and currently University of New South Wales (UNSW) Aviation course facilitator of the postgraduate course, Aircraft Accident Investigation Techniques.

Let’s get into it…

What is Just Culture?

Just Culture encourages the reporting of near-misses, operational errors, abnormalities, and system malfunctions without fear of punitive action, promoting learning and improvement. It is a cornerstone of traditional aviation and fosters an environment where safety and transparency are paramount. It aims to ensure that human mistakes are not met with harsh punishment but are analysed to enhance systems and prevent recurrence.

Integrating Just Culture into the Drone Industry: A Path to Safer Skies

A particularly fascinating aspect of the drone industry is that many participants in the industry – whether pilots, software providers, hardware manufacturers, and the various other players  – are not from a traditional aviation background.

Those from a traditional aviation background are likely to have had the Just Culture attitude drilled into them and are therefore more likely to speak up if there is a failure, problem or incident, with some comfort that (recklessness or wilful misconduct aside) they will not be punished, but rather failures in the environment, the systems,  and training will be investigated before a finger is pointed at the person reporting.

While the proposition is not that those not from traditional aviation will necessarily act differently; rather that if this type of culture and thinking has not been drilled into them throughout their career, then natural instinct may typically be toward a “reporting means trouble”  mindset.

The upshot is that the values from traditional aviation may simply not be as embedded into the drone industry as it is in traditional aviation. This of course varies depending on the person, their training, their previous experience and current workplace.

The Case for Just Culture in the Drone Industry

Integrating Just Culture into the drone industry isn’t just a regulatory nicety — it’s now a necessity. As drones become increasingly integral to various sectors, the potential for incidents grows. A Just Culture approach can mitigate risks by fostering an environment where operators feel safe to report near-misses, operational errors, and system malfunctions. This open reporting can lead to valuable data collection, helping to identify trends and develop preventive measures.

Steps to Integration

A greater integration of Just Culture into the drone industry might include one or more of the following 4 steps:

1. Regulatory Support: Just Culture is part of the Civil Aviation Safety Authority’s (CASA) regulatory philosophy, which includes that:

“CASA embraces, and encourages the development throughout the aviation community of, a ‘just culture’, as an organisational culture in which people are not punished for actions, omissions or decisions taken by them that are commensurate with their experience, qualifications and training, but where gross negligence, recklessness, wilful violations and destructive acts are not tolerated.”

Encouragingly, CASA has developed a user friendly 9-booklet resource kit for all aviators to assist in the development of a Safety Management System (SMS) which is accessible here.

Booklet 9 of this SMS resource kit is specifically for drone operations, is accessible here, and states that:

“An effective SMS also requires a positive safety culture to be in place, this includes what is known as a ‘just culture.’ A just culture encourages and supports people to provide essential safety related information in a non-threatening environment but is clear about where the line is drawn between acceptable and unacceptable safety behaviours.

The ideal safety culture supports people and systems, recognises errors will be made and believes blaming individuals will not solve problems. A positive and supportive safety culture encourages open and honest reporting, seeks to learn from its failures and is open and fair in dealing with those involved.”

and

“ReOC holders should strive to achieve a positive safety culture which includes a just culture. In these environments, the workforce will be encouraged to report hazards without fear or favour. Hazard identification is not a process that should be left up to the safety manager or safety department – they are there to facilitate the process – as all areas of the organisation should contribute.”

Clear guidelines that protect operators from punitive actions when they report errors in good faith are essential. CASA’s Enforcement Manual, accessible here, sets out how it deals with aviation regulatory breaches and provides that:

“Beyond our legal obligations to ensure procedural fairness, our enforcement processes are in line with CASA’s Regulatory Philosophy and consistent with our principles of just culture, as set out in CASA’s Directive on Just Culture in the Exercise of CASA’s Enforcement Powers and the Use of Safety Information (for more information see here).

2. Industry Standards: Developing industry-wide standards and best practices will help create a unified approach to safety. Organisations like the International Civil Aviation Organization (ICAO) and industry associations, can play a pivotal role in establishing these norms.

3. Training and Education: There are multiple avenues where Just Culture can be introduced, whether at ARN, accreditation, RePL or ReOC stages.

There ought to be significant focus on emphasising the importance of reporting and the assurance that such reports will lead to improvements rather than punishment.

However, what is said in a classroom or workplace is only as effective as what is implemented at the organisation level. To this end, organisations need to embed a Just Culture into their existing culture so as to encourage reporting.

4. Understanding humans in the System: Human Factors specialists have been telling us for many years that humans make errors, no matter their level of skill or ability.  Things such as the operating environment, fatigue, sleep management, distractions, time constraints etc. will affect any competent operator on any given day. 

It is important to recognise that errors will occur and that, in most instances, they are not deliberate.  Organisational and operational systems need to be robust enough to cope with human errors and one way to achieve this is to encourage reporting of slips and lapses so that procedures can be enhanced to prevent a recurrence.

Just Culture recognises that the reporting of such events should be non-punitive and encouraged to strengthen the operating system.  This can be done by way of reviewing or introducing procedures, checklists and the like. This is a way to improve an operators safety culture, working on continuous improvement and encouraging open communication.

Just Culture in accident and incident investigations – drone  organisation obligations

Drone organisations must face the possibility of being involved in a reportable Incident, Serious Incident or Accident, as defined in the Transport Safety Investigation Act (2003).

As a result, the operator may be subject to an investigation conducted by the ATSB.

The ATSB reporting requirements for drones are detailed in this handy checklist of what is required and who needs to report, which are fully set out in the Transport Safety Investigation Regulations (2021).

Australia is a signatory to the Convention on International Civil Aviation (the Chicago Convention).  As  a result, Australia conducts all aviation investigations in accordance with the International Civil Aviation Organization (ICAO), Annex 13, Standards and Recommended Practices for accident and incident investigation. This Annex embodies the principles of Just Culture and states this explicitly in Section 3 – Objective of the Investigation:

3.1  The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents.  It is not the purpose of this activity to apportion blame or liability.

This is mirrored in Australia’s Transport Safety Investigation Act (2003) which states at s. 12AA that:

(3)  The following are not functions of the ATSB:

(a)  to apportion blame for transport safety matters;

(b)  to provide a means to determine the liability of any person in respect of a transport safety matter; …

Concluding remarks and take-aways

The drone industry stands at a critical juncture. Embracing Just Culture offers a path to safer skies and a more robust industry. By learning from the successes (and failures) of traditional aviation and adapting relevant principles to the unique challenges of the drone industry, we can foster a culture of safety, transparency, and continuous improvement. In doing so, we not only protect the public but also ensure the sustainable growth and longevity.

Finally, there are ways that drone operators can incorporate Just Culture into their organisation’s documented practices and procedures such as:

  • Review CASA Booklet 9 – Safety Management Systems for RPAS and consider implementing some of the guidance provided.
  • Incorporate Just Culture into reporting systems and inform and train staff on its application.
  • Encourage reporting of incidents, accidents, mishaps and abnormalities, so that the organisation can learn from them – “no more blaming, no more shaming, just more training”.
  • Develop procedures for Accident and Incident reporting in the event of an ATSB reportable event.

For further thoughts on Just Culture in Aviation, the UNSW School of Aviation held a discussion panel featuring experts from CASA, Qantas and the International Air Pilots Association in November 2023, accessible here.

Thanks for reading and please reach out if you would like to discuss anything in this article or aviation in general.

The Drone Lawyer

The lawyers in your corner of the sky

25 July 2024