Just culture

At the national level, ‘Just Culture’ has been defined in aviation as an operating culture in which frontline operators or other persons are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated. Just Culture principles guarantee an atmosphere of trust encouraging individuals to report safety information and assuring them that the information will be appropriately handled and taken into account in safety management. 

The definition of Just Culture varies in different contexts. In the Occurrence Regulation, Just Culture has been defined as follows:
“For the purposes of this Regulation, Just Culture means a culture in which frontline operators or other persons are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated.” 

Traficom has included the key elements of implementing the principles of Just Culture in its definition.

What constitutes Just Culture

Organisations are vulnerable to human errors and characteristics. The aviation system is comprised of organisations that consist of individuals and work in an operating environment in which a large number of individuals is needed to run the system. Before the COVID-19 pandemic, commercial air transport employed over 63 million people at the global level. Organisations’ dynamics, capabilities and prevailing organisational culture change and adapt slowly or rapidly, as the individuals are constantly influencing them – for better or worse.

Just Culture is a safety management`s "tool" that enables organisations to learn about issues that their employees identify as factors affecting or potentially affecting safety. Just Culture also covers the appropriate processing of this safety information and the benefits gained by the organisation as a result of improving the organisation’s operations. Employees are shown that the issues they bring up, including unintentional mistakes, are processed in a just manner and that the reporting of issues is valued by the organisation. They know that their own actions can impact the development of safety operations.

Just Culture builds an atmosphere of trust at the state, organisational and community level and encourages individuals to report safety observations. An organisation must not apply measures interpretable as a penalty or sanction to an individual, discriminate them or hinder their work performance based on a report of safety issues or occurrences, i.e. if the individual has acted in conformity with the Occurrence Regulation.

What does not constitute Just Culture

Just Culture does not release persons from their usual responsibilities. It does not protect a person in the case of intentional non-compliance or if the person has clearly and gravely ignored an obvious risk and seriously neglected the professional duty of care required under the circumstances, resulting in predictable damage to a person or property or seriously endangering the level of aviation safety.

Why is Just Culture so important to organisations?

Although personnel is obligated to report any issues and occurrences they observe, high-quality and comprehensive safety information cannot be obtained without the established and well-maintained confidential safety culture and active communication about it within the organisation. Employees must be able to trust that the principles of Just Culture are followed in everyday operations. High-quality and comprehensive safety information is an important source for the organisation’s safety management system and thus one of the key prerequisites for its performance.

Just Culture in organisations  

Just Culture is closely associated with reporting culture and occurrence reporting, the obligations for which are directly derived from the Occurrence Regulation (EU) 376/2014 (see the page on reporting culture for more details). Occurrence data are one of the key information sources for the organisation’s safety management system. In addition, sections 125, 126 and 128 of the Aviation Act apply to occurrence reporting. Section 128 (Use of occurrence information) concerns authorities’ and operators’ observance of the principles of Just Culture.

Just Culture encourages personnel to report information related to safety. An organisation must not apply measures interpretable as a penalty or sanction to an individual, discriminate them or hinder their work performance based on the fact that the individual has acted in conformity with the Occurrence Regulation. The Occurrence Regulation also sets obligations regarding the use of data and ensuring its confidentiality. According to Article 15(3b) (Confidentiality and appropriate use of information), the use of the information is limited to “what is strictly necessary in order to discharge their safety-related obligations without attributing blame or liability; in this respect, the information shall be used in particular for risk management and for analysis of safety trends which may lead to safety recommendations or actions, addressing actual or potential safety deficiencies” – i.e. as a data source in safety management.

Subject to Article 16 (Protection of the information source), reported occurrences shall be processed in an appropriate manner in the organisation. The reporter must be able to rely on the fact that the aim of the processing is to develop and improve safety. Under Article 16(9), employees and contracted personnel who report or are mentioned in occurrence reports collected in accordance with the Occurrence Regulation shall not be subject to any prejudice by their employer or by the organisation for which the services are provided on the basis of the information supplied by the reporter. The protection under these paragraphs does not apply to situations referred to in paragraph 10. In practice, these are cases of wilful misconduct or gross negligence.

Definition and communication of Just Culture ground rules

Under Article 16, each organisation established in a Member State shall, after consulting its staff representatives, adopt internal rules describing how Just Culture principles, in particular the principle referred to in paragraph 9, are guaranteed and implemented within that organisation.

It is important that organisations define, describe and communicate their ground rules, i.e. internal safety-related practices, and how deviations from these practices reported to the organisation are processed. When the processing processes and minimum requirements for decision-making have been defined and communicated to the entire personnel, everyone is on the same page regarding just operations. It is also important to remember that e.g. additional training deemed necessary is not a penalty but a measure to ensure safe operations in future.

On the “Cultural elements – instructive material” page, you can find instructions and decision-making charts with examples of how occurrences are addressed in line with the principles of Just Culture. 

Similar to organisations, individual pilots – both professionals and enthusiasts – are responsible for the safety of their operations.

Aviation professionals – liability

For an aviation professional working in the organisation, this means that the individual shall, for their own part and in their assigned role, observe the regulations and obligations related to the performance of their duties, follow the organisation’s practices and instructions, and maintain the competence level required for their job. Under the Occurrence Regulation, the individual is obliged to report information affecting safety, i.e. notify Traficom of any occurrences, incidents and accidents they observe, as well as report serious incidents and accidents to Safety Investigation Authority SIA (see the “Reporting culture” page and Traficom’s Advisory Circular GEN T1-4 for more details). In practice, aviation professionals report their observations through the organisation’s reporting system. The duty to report also applies to mistakes and occurrences attributable to the reporter themselves. 

Aviation enthusiasts – liability

Aviation enthusiasts have mostly the same responsibilities as aviation professionals but they are applied in proportion to their own role and obligations regarding the recreational activities in question. Enthusiasts do not have the organisational practices and instructions to follow, which underlines their responsibility to know the requirements and obligations set for aviation. In addition, enthusiasts are responsible for maintaining and improving their competence to ensure safety.

Aviation clubs and communities can support aviation safety and maintain and develop the safety of their activities by means of safety management. Clubs and communities establish their own safety culture, which is developed and improved by the same factors, challenges and opportunities as any other safety culture. 

Reporting of own mistakes and occurrences

Most minor occurrences are situations were safety was not compromised, the risk level barely rose and at least the majority of safety barriers functioned well. For example, a person may have observed something in their own conduct or identified a situation where safety could have been endangered or a procedure that could be improved in terms of safety.
The majority of reports filed concern minor occurrences. Reports related to a person’s own actions and observations often contain information that would not have been obtained without the person’s own interest to report the situation. Moreover, the transparency and extent of the information provided by the person depends on their desire to share the information. This is the unique characteristic, value and challenge of occurrence information in aviation.

How to obtain high-quality information from individuals?

Although personnel is obligated to report any occurrences they observe, high-quality and comprehensive safety data cannot be obtained without the establishment and maintenance of a Just Culture and active communication about it at the state level and within the organisation. Individuals must be able to trust that the principles of Just Culture are followed in everyday operations. Reports and the data produced must be processed in an appropriate manner, and the organisation must not apply measures interpretable as a penalty or sanction to an individual, discriminate them or hinder their work performance based on the fact that the individual has acted in conformity with the Occurrence Regulation. The ground rules must be defined and communicated at the organisational, state and e.g. club level. The reporter must be able to trust that the genuine aim of the processing is to develop and improve safety.

In addition to following the ground rules, it is important that individuals are encouraged and motivated to produce safety information and report their own errors and misconduct. Individuals are more eager to report issues if they receive information about how their reports are used to improve safety.

Just Culture in regulatory work 

The safety information obtained through occurrence reporting is a key source of information for safety management at the national level, and it is utilised in the risk- and performance-based maintenance and improvement of safety (see Finnish Aviation Safety Programme FASP, sections FASP 2.5 and 2.6).

Traficom is responsible for the confidentiality and appropriate handling of occurrence information (Air Safety Reports) as defined in the Occurrence Regulation, and enters the reports received in the European occurrence database (ECCAIRS) without personal identity details. Finland exchanges information with other countries using the ECCAIRS database according to the Just Culture principles. At Traficom, occurrence reports are processed and analysed by a safety information team operating separately from the other oversight functions.  

The ‘Just Culture’ principles are followed in the handling of data received through Air Safety Reports; the authorities will not take legal action because of an unplanned or unintentional offence that comes to their attention because of compliance with occurrence reporting procedures, except in the event of gross negligence or an action punishable under the Criminal Code.

Traficom monitors aviation organisations based on risks and performance and evaluates the performance of their safety management systems (SMS) (see Finnish Aviation Safety Programme FASP, section 3). Traficom pays attention on the level of the organisations’ safety and reporting cultures as well as compliance with the principles of Just Culture as part of the SMS assessment. 

Reviewing body for Just Culture violations required by the Occurrence Regulation

Under Article 16 of the Occurrence Regulation (Protection of the information source), each Member State shall designate a body to which employees and other contracted personnel may report alleged infringements of the principles of Just Culture in the processing of their report. In Finland, the designated body is a reviewing body within Traficom.

Every five years, each Member State shall send the European Commission a report on the application of Article 16, and in particular on the activities of the body designated pursuant to the Article. The report must not contain personal data.

Advance administrative arrangements under the Occurrence Regulation

Subject to Article 15(4) (Confidentiality and appropriate use of information) of the Occurrence Regulation, Member States shall ensure that their competent authorities referred to in Article 6(3) and their competent authorities for the administration of justice cooperate with each other through advance administrative arrangements. These advance administrative arrangements shall seek to ensure the correct balance between the need for proper administration of justice, on the one hand, and the necessary continued availability of safety information, on the other hand.

In practice, this means that Traficom shall review and agree on the necessary procedures with e.g. the police administration in order to ensure that all occurrences are processed according to the principles of Just Culture under the Occurrence Regulation.

Traficom receives and processes all occurrence reports filed pursuant to the Occurrence Regulation. The level of reporting in Finland is good and, in a normal year, Traficom receives approximately 10,000 occurrence reports concerning aviation in Finland. All or nearly all of the reports concern unintentional mistakes or occurrences and are used to improve safety.

Traficom has a separate process for processing reports involving suspicions of intention or gross negligence. If there are suspicions of a violation or negligence of aviation regulations and provisions resulting from intentional misconduct or gross negligence, the case is assessed by a team of experts.

If the team of experts finds that the case involves intentional non-compliance or if the person has clearly and gravely ignored an obvious risk and seriously neglected the professional duty of care required under the circumstances, resulting in predictable damage to a person or property or seriously endangering the level of aviation safety, administrative measures may be applied (cancellation of a permit, warning or reprimand). Depending on the situation, a police report may be filed instead of taking administrative measures.

The police have a general obligation to act under legislation, which means that the police are obligated to investigate a reported alleged offence or infringement. Under the Occurrence Regulation, Traficom and the police work together in cases concerning aviation. The aim of this cooperation is to take into account the protection of the reporter under the Occurrence Regulation and the incompleteness of the processing of the report at Traficom.

If an occurrence report has been filed or the case is already under investigation with the Safety Investigation Authority (SIA), the police determine the need for launching or stopping preliminary investigation until the occurrence report has been processed or the SIA investigation has been completed.

Instructional material for practical application in SMS work: Just Culture decision-making charts

• This link leads to the decision-making charts