Just Culture and the Role of Accountability Continued from page 37 attempted to level the wings, the con- trols felt strange, and the pilot noticed he wasn’t able to stop the plane from banking. Thinking quickly, the crew reduced power on one engine and used trim to maintain some control. They declared an emergency and explained what they were seeing to Air Traffic Control (ATC). Using differential engine power and trim, they eventually landed the airplane. A quick check of the logs showed the previous night’s maintenance, and the wingtip was removed. There, inside the wing, was a headlamp, its straps wrapped around the aileron push- rod. Hearing the news, James, the technician, felt sick. A quick-thinking crew—and a lot of luck—had been the only things that prevented a catastro- phe. The investigation that followed was thorough, but it didn’t focus solely on James’s actions. It looked at the system in a broader sense, seeking to understand the full story rather than affix blame. Sure, there were rumblings of termination amongst the crews; but, in the end, the investiga- tion report was clearly communicated throughout the organization, and several system-level ideas, from tool control to checklists, were examined as ways to create a more resilient process. James was the one that did the work; but the abandoned head- lamp could have happened to anyone. The investigating team—along with maintenance representatives—worked hard to identify opportunities for learning. Of course, leaving a tool or a light in a wing wasn’t something the organization could tolerate, but they understood that firing James did nothing to solve the matter of how the lamp got left there in the first place. Aviation Business Journal | 3rd Quarter 2018 This sort of thinking doesn’t always happen, though. An air charter opera- tor taking delivery of a new aircraft for their fleet experienced the flip side of the just culture coin. While flying back to their home base from the fac- tory, after accepting the aircraft, the crew correctly read back an altitude clearance from the controller. Though the altitude may not have been nor- mal outside of positive ATC control, it wasn’t unusual to be assigned varying altitudes in the area to accommodate traffic. After verifying their assign- ment, nothing further was heard from ATC. The crew worked to reach con- trollers, trying a dozen times to reach them. Meanwhile, a 737 flying in the opposite direction on the same airway was also assigned the same altitude, though earlier and on a different fre- quency, preventing crews from hear- ing each other’s clearance. During the period where the charter operator was unable to reach ATC by radio, the aircraft collided without ever having seen one another. Though the smaller aircraft was damaged, it was able to land at a nearby military base. The 737 tragically lost control and all on board were killed. The crew and passengers of the charter flight were stunned and were further devastated by the news of the downed airliner. At this point, the wheels were already in motion to criminalize the actions of the charter pilots. They were detained and their passports were confiscated shortly before they were charged with “endangering an aircraft.” Although the function of an air traffic control system is generally understood to be a complex undertaking, with many interacting elements, the crew were singled out by regulators, officials, military and news media as having caused the accident through reck- lessness. Subsequent investigation revealed widespread system issues in the ATC organization, as well as a series of communication issues compounded by malfunctions and infrequent maintenance. Despite that, the government sought culpa- bility, believing that human error was a cause, not a symptom. The crew and passengers spent years battling legal issues and disagree- ments persist to this day about the nature of the accident’s causation. The difference between the two examples is stark. Of course, the difference in outcomes is equally so; one resulting in multiple fatali- ties, while the other was only a close call. This difference is often appar- ent in cultural response to failure, as we often naturally, if illogically, apply more weight to catastrophic results. The challenge, though, is in understanding work and systems from the perspective of the prac- titioner—regardless of the sever- ity of failure—and in restoring the system to its intended function. WHY JUST CULTURE? Without justice, it is difficult to fully know what’s really going on within our organizations. All those times we make it through a shift uneventfully are lost as learning opportunities without a culture that allows people at all levels to com- municate openly about the reality, good and bad, of our processes and systems. For customers, the benefit is an organization that focuses on improving their experience rather Continued on page 41 39
