Whose Fault is it?

When a Venetian merchant of the 16^th century demanded “a pound of flesh” as collateral from a nobleman, the latter was spared from an insolent death when a woman justly stated that the contract required flesh and no blood. The practice of “Just Culture” follows a similar parallel whereby an errant employee is treated fairly in an atmosphere of trust and an ecological approach is applied to investigating the situation at hand. But how many Air Navigation Service Providers (ANSPs) are ready to adopt the principles of "Just Culture" to safety and /or error management?

The phrase << a pound of flesh>> was made famous from a Shakespearean play – The Merchant of Venice (1656) and it questioned the justice system back then. It highlighted that penalties could be sometimes harsh and even spiteful. It also referred to the absurdity of sticking to the letter of the law instead of weighing the contextual circumstances and considering the moral principles. The merchant’s daughter had eloped and it was an opportunity for him to levy his anger against charming noblemen.

The culture among Venice merchants certainly was not helpful to alleviate the situation since death by the sword was the punishment for any crime among them. And the nobleman, according to the legal system deserved to die. He had impetuously agreed to a contract using his life as a guarantee. But a third person applied the principle of “Just Culture” and the nobleman was spared a rash death.

To increase safety, the concept of “Just Culture” has been introduced into the ATC arena within the last decade to encourage not just the reporting of errors, but also the adopting of an ecological approach towards the investigation of errors and the meting out of fair treatment to the errant controller.  An ATCO may be afraid to report an error in the face of punitive action and isolation from other workmates which includes personal embarrassment. But implementing “Just Culture” policies imply that ANSPs admit the deficiencies in their system, an action that some of them may not be quite ready for.

According to Sidney Dekker, Professor in Human factors and Flight Safety, error management involves a complete reversal in the mindset of management from keeping tabs on incompetent ATCOs to a deeper cognizance of the complex dynamic systems with which we work in ATC. Taking an ecological approach means that managers, particularly seniors and executives understand that safety in ATC expands beyond achieving zero incidents and accidents. In other words, they will examine their system to determine the flaws that could have contributed to the error which could be likened to weak links in a chain and then work towards resolving those weak organizational links.

We should not overlook the perceptions of our senior managers and their level of organizational commitment which play important roles. Under a “Just Culture” system, they too will be held accountable for deficiencies in the daily organizational functions of our ANSPs. The well-trained senior manager will readily recognize that a negative occurrence is not an indication of personal failure and the need to be fearful of incrimination. No complex, dynamic system is infallible. But are ANSPs really ready to embrace the mode of “Just Culture” within their organizations?

For this concept to flourish, the organizational culture must be stable. If an ANSP lacks aptly qualified management personnel and a well-coordinated governance structure, what kind of organizational culture do you think will be present?
The layout of organizational goals is also important. Without a well-laid structure, the goals of the ANSP will remain incompatible and clashing. In such an atmosphere, the probability or the risk of an error happening is increased because the organizational practices are unsafe. In other words, there is a level of disorder because good organizational ethics are not fully endorsed in the workplace.

In ANSPs where the organizational ethics are questionable, our ATCOS will not only feel a false sense of security from their job. Their discomfort will be heightened or increased whenever operational safety is compromised. For these ATCOs, the blame-game will take a toll on their well-being as the work atmosphere becomes heavy with the issue of whose fault it is.  

 "As managers, we need to shift our thinking from command and control to coordinate and cultivate - the best way to gain power is sometimes to give it away." - (Thomas Malone, 2004)

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