Towards the harmonisation of Just Culture across organisations: the London Luton Airport case

Organisations at an airport, including the airport authority, airlines, air traffic management, ground handling and other services, must all have a Just Culture policy and system in place, according to EC regulation 376/2014. This is to protect employees and also to promote reporting and learning from safety-related events or hazards. However, there may be differences in such policies and the ways in which they are enacted, including the openness of the culture, the investigation processes, and the degree of authentic support from senior and middle management. As part of the H2020-funded Future Safety Sky project, and in collaboration with London Luton Airport (LLA), a Just Culture Framework has been developed which acts as an over-arching Just Culture policy for all companies operating at the airport. This paper shows how this framework was developed and ratified, with input from a number of companies based at LTN.


INTRODUCTION -THE LUTON SAFETY STACK
At an airport there are many organisations who have to work together to enable smooth and safe airport operations for passengers, freight and business users. Such users range from airlines, air traffic control and ground handlers, to de-icers, fuel services, baggage handlers, caterers, construction workers and cleaning services. These businesses are all connected, rather than working in isolation. If one of them has a safety problem, then the impact can affect the entire system.
All companies operating at an airport are part of a complex safety chain, and all are legally bound under EC regulation 376/2014 a to have a Just Culture policy and Safety Management System in place. The SMS relies on the reporting of potential safety issues. Yet reporting is unlikely to take place if blame and retribution for the reportee might be the result. In order to ensure safety globally at the airport, there can be no weak links in the reporting from any one company. Sharing data and putting safety first needs to take precedence over economic competition. However, at the airport level, the range of companies is such that there are multiple scales of operations and resources, as well as different organisational cultures. Some companies already have Just Culture policies and practices that they apply rigorously, while a https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32014R0376&from=EN for others the blaming culture might still be the norm. Hence, developing a common Just Culture Framework, acting as an over-arching Just Culture policy for all companies operating at an airport, is one way to improve the airport safety culture. While accommodating existing individual company Just Culture policies, this over-arching framework provides a common vision and principles for the organisations who, as yet, have an under-developed policy and are still on their pathway to Just Culture.
The Horizon 2020 Future Sky Safety (FSS) programme (2015-2019) was an EU-funded transport research programme, with a budget of around €28 million, and brought together 33 European partners to develop new tools and new approaches to improve aviation safety. One of the programme objectives was to reduce the likelihood of organisational accidents in aviation via the evaluation and enhancement of safety culture, often pithily described as 'the way safety is done around here' (see [1,2] for reviews of safety culture theory and approaches). Within this framework, FSS partners tailored safety culture surveys, initially developed for Air Traffic Management [3,4], to other aviation actors such as airlines [5], airframe manufacturers and companies operating on the ground at an airport. The airport is a special case, as operational safety depends on synchronised and safe operations between multiple organisations -'joined-up' safety -creating a 'safety chain'. In such systems, any organisation is only as safe as the weakest link in that chain. Based on this premise, FSS decided to examine the Safety Culture across the whole 'Stack' of companies present at one airport, from aircraft manufacturers, to ground handling, de-icing services, airport operations, airlines and air traffic control (the term "stack" was coined because the original concept presented a vertical representation of the companies, from the ground upwards, and used this word to describe it).
The work began in late 2016 with six independent safety culture surveys of key organisations at London Luton Airport. Following the independent safety culture surveys, focus groups were organized by company and each organisation received a confidential detailed snapshot of its own safety culture, its strengths and opportunities for development. During the first meeting, all six organisations decided to waive their confidentiality and share information on each other's surveys. They were not interested in the detailed results for every question, but wanted to know the best practices of their business partners, looking for support on their individual path towards a better safety culture. During the ensuing conversations, it became clear that they all had something to learn from each other. There was not necessarily a 'best' safety culture, and furthermore, in certain areas they all shared similar problems. The Luton Airport Safety Stack [6] was born at that meeting and has continued with quarterly meetings attended by multiple stakeholders.

The Need for a Just Culture Framework
At its 8th such meeting in September 2018, the Stack had a specific item titled Open Discussion on Just Culture -Towards a Just Culture Framework for LTN. EUROCONTROL presented a proposal for the Luton Safety Stack Just Culture Framework, which would be on four levels. The top level, Level 1 would be a short and high level overarching or 'umbrella' policy, with a common vision, which could accommodate existing Stack Member Just Culture policies as well as encompassing those organisations who as yet had no policy. Level 2 would go into more detail about the 'why, what and how' of Just Culture at Luton, with key principles and benefits, the expected behaviours and attitudes of staff and management with respect to Just Culture (via 'charters' for each), the agreement that for all actions there are consequences, as well as showing models (e.g. the FAIR model), and touching on issues such as 'work as intended vs work as done' and restorative justice, and covering best practices in investigation. At Level 3 all individual organisations would then have their own policies and investigation processes, or e.g. sign up to commonly available approaches such as LLA's. Level 4 of the Framework would be a common training module for Just Culture at Luton. An Appeals Board could also be set up at the level of the Stack for special cases.  To develop an over-arching framework policy and principles that all LTN organisations can sign up to,  To have processes underneath that are fair, balanced and realistic, and will gain the support of staff and management alike  To provide information about this framework in a clear and compelling way.

Developing the Just Culture Framework
The first discussion thread of the workshop addressed the following question: Why do we need an overarching Just Culture framework? Participants elaborated the following list of arguments in favour of a common framework:  Everybody should have a common just culture foundation and then add onto it.  Have a very simple statement on how to treat people, even if you are a small company.  Bringing up Just Culture to the front level. Give leeway to companies, but we are a community at Luton airport, and staff need to be confident they will be treated the same way.  Have a framework for all policies to fit underneath.  A very simple common statement that is understandable and 'sellable.' This is how you can expect to be treated, this is how we do it.  Move away from a sacking/firing culture.  There are lots of policies, but that's not enough. The application & interpretation of these policies is the important point. We need to focus on the whole line, and not just the front line.  If the airport has a Just Culture Framework, we know how this is done across the airport. Background information had been sent in advance and the meeting discussed the official definition of Just Culture. EU Regulation 376/2014 requires aviation organisations in the European Union to adopt and maintain a proactive, evidence based Just Culture. It states that (Article 2 Definitions (12)): 'Just culture' means a culture in which front-line 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; EU Regulation 376/2014 also mentions that 'Just culture' is an essential element of a broader 'safety culture', which forms the basis of a robust safety management system.
The regulation aims to encourage the open reporting of safety occurrences. There should be no punishment of front-line staff for making genuine mistakes nor for reporting safety-related information. However, Just Culture does not absolve individuals of their normal responsibilities.
Participants reviewing this official definition commented that Just Culture is meant to make us safer, and this notion is not there in the official definition which focuses more on punitive actions. Moreover, the term of "willful" needs to be clarified as it may not have the same meaning for everyone. Stack partners also pointed out the absence of reference to organisational influence in EU 376/2014, which should be added to the common framework.
Other policies were reviewed, from airlines, leading Air Traffic Services providers, and also some outside the aviation industry, e.g. the health service. The following elements are extracted from some of these:  [Just Culture]…is an atmosphere of trust in which people are encouraged, or even rewarded for providing essential safety-related information.  Just Culture policy…encourages mutual trust, focuses on intent rather than outcome, provides protection for reporting, and encourages a learning culture, while highlighting the role of training, though it does not tolerate unacceptable behaviour.  …If an individual reports an event implicating himself, he (or she) will be treated justly.  …If you make an error, you are cared for and supported. If you behave in a risky manner by not adhering to policies, you are asked why first, before being judged. If you behave recklessly and intentionally put your patients or yourself at risk, you are accountable for your actions. With respect to the latter extract, participants noted the "caring" aspect which relates to restorative justice and is not explicitly present in other policies. A set of key principles was then presented to the Just Culture workshop participants, and they selected those that seemed most important to them, listed below.
 A Just Culture is a culture of trust, learning and accountability  The purpose of investigation is to establish the facts and prevent recurrence.
 Safety needs open, honest reporting of safety-related events, however small, to make our airport community safer, to maintain existing safety levels, and to prevent accidents from happening.  We're all human, we all make mistakes. We don't look for blame, we want to learn and improve the system as a whole.  We will protect the identity of reportees and support them should they be subject to external exposure.  We will share safety lessons learned with the entire community so they can be openly discussed.  Application of the Just Culture process requires understanding of the job and its local working environment, in particular what is 'normal practice.'  If ever you are unsure about whether something is safe or not, you can talk to a Safety Leader (staff in any LTN company who undertake specialised safety leadership training).
 Each organisation at LTN may have its own specific Just Culture system and processes, but these general [framework] principles are applied across all organisations at LTN.  If someone reports an event in which they are implicated and there are large financial consequences, they will still be treated fairly.  If you have experienced an incident that may affect your wellbeing, you will be supported.  We expect all 3rd party companies contracted to carry out safety-related activities at our airport to ensure that they have, and encourage, an open, just and fair reporting system which results in honest and fair treatment and safe and robust operations.  Just Culture should give staff confidence in the organisation's occurrence reporting system, so that they feel safe to report.  Just Culture is an essential element of the broader safety culture of the organisation.
The consensus of the workshop organisations was that the framework needed to be practical and avoid jargon. The selection of the most important principles led to the establishment of the Just Culture Framework for Luton ordered along the following headers:  Just Culture (definition)  It's the law  Accountability  Safer through Reporting  Trust  Safety Learning  Fairness in Decision-Making  Many systems, one framework  Safety Leaders are there to help The resultant Just Culture Framework is shown below.

Just Culture
A Just Culture is one of trust, learning and accountability. It recognises that we're all human, and we all make mistakes. At LTN, we don't look for blame, rather we want to learn and improve, sharing safety lessons learned with the entire community so they can be openly discussed. In this way, Just Culture is an essential element of safety culture.

It's the law
Just Culture is no longer optional -it is a legal requirement. The official definition of Just Culture is 'a culture in which front-line operators or other persons are not punished for actions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, willful violations and destructive acts are not tolerated.' Accountability Accountability is important because aviation has serious risks, and persistent unsafe behavior cannot be tolerated. We place strong emphasis on learning to be safer, through a reporting environment based on trust.

Safer through Reporting
Safety comes first at LTN, and in order to keep our airport community safe we need open, honest reporting of safety events, however small. This is achieved by having a strong Just Culture across all organisations at Luton Airport, so that staff have confidence in their organisation's occurrence reporting system, and feel safe to report.

Trust
In order to build trust, the identity of reportees is kept confidential. Their explanation of what happened, and why, is always heard out first. If you report an event in which you are implicated, even if there are large financial consequences, you will still be treated fairly. Furthermore, if you have experienced an incident that may affect your wellbeing, you will be supported.

Safety Learning
The primary purpose of investigation is to establish the facts around an event, including what is considered 'normal practice', and then put in place measures to prevent its recurrence. Open and honest two-way dialogue is essential to this investigation process. Lessons learned will be fed back to you and then shared across other organisations at Luton Airport. This is what safety does, and how your reports keep the entire community safer.

Fairness in Decision-Making
Following an investigation, each organisation will have its own decision-making process in which you will always be treated fairly. In almost all cases recurrence is prevented by retraining, changes to procedures, or other means. In a very small number of cases, where rules are broken intentionally or repeatedly, disciplinary action may result, because safety comes first.

Many systems, one framework
The general principles in this Framework are applied across all organisations at LTN. Furthermore, we encourage all 3 rd party companies contracted to carry out safety-related activities at our airport, to ensure that they have an equivalent open, just and fair reporting system which results in honest and fair treatment, and safe and robust operations.

Safety Leaders are here to help
Remember, if ever you have any questions about Just Culture or safety, you can talk to a Safety Leader.

Investigating Differently
Day 2 of the Just Culture workshop focused on How Just Culture currently works in the Stack so that partners could share experience and ongoing practices and also explore various actual cases. The discussion in this area concentrated on the investigative approaches and decision aids used by the organisations around the table.
One organisation uses a flowchart that includes behaviour (team member & team & supervisor or manager). Organisational & systemic factors will be included and the taxonomy will be reviewed in the next update. Another company had a much simpler process. Most often, the incidents result from honest mistakes, and only extremely rarely from intentional actions.
A third company stated that a written statement is taken at the time of the incident and e-mailed immediately. The initial investigation focuses on fact-finding (no blame) and leads to a written record. If this is a simple incident, the issue is dealt with immediately. If a disciplinary type hearing is necessary (serious incident), another manager will write the report. A substitution test approach might potentially follow (i.e. could someone else in the same situation have made the same mistake?). Review at company level is also independent. Incidents and accidents are all classified in five predetermined categories. Their investigation policy focuses on reporting & investigating; they want to understand the facts, not to punish and blame.
Another Stack member company has a well-established investigation process. Investigations are conducted by the Audits & Compliance department, and if necessary HR and their OPS are also involved. Recommendations are issued from the report. Decisions are taken independently. Most occurrences are related to vehicles. This company is considering different alternatives including a points system for airside driving licences. The decision-making process is often based on recurrence (has this person had a similar incident before?).
For LLA, as the airport authority, they are typically the first responder and cover all companies. LLA uses the FAIR b model for third parties and their own staff as well. The FAIR model starts with whether it was intentional or not, gathers the background on people, then analyses whether organisational or individual factors were involved. Investigation is quick, and involves a discussion with staff to determine their attitude to risk. Everything is recorded, and there are regular checks on procedure application. LLA also uses the Five Why's technique c to get to the bottom of the situation.

Restorative Just Culture
Most companies operating at Luton Airport apply "Restorative Just Culture" [7], finding solutions through re-training, or even change of activity. Usually, a single instance will not lead to dismissal (even for a major incident). Companies involved in the workshop noted that, in broad terms, only 1/30 to 1/50 incidents results in disciplinary action. Dismissal is extremely rare (1/300 or less). Recurrence is clearly taken into account in the final decision.
A discussion on Restorative Justice ensued. It was felt that with the current focus on fairness, strong investigation domain expertise and wellbeing support for staff following incidents, most Luton organisations already embody significant elements of Restorative Justice. It was agreed, however, that support in case of a traumatic incident (restorative justice) must also be part of Just Culture.

Conclusion
At its 10th meeting in March 2019, the Luton Stack participants agreed that the Luton Just Culture Framework should be the minimum standard expected from any company operating at Luton Airport. A communication to this effect from the Luton Stack was sent out by LLA who will ensure compliance monitoring of this Just Culture framework.
A video has been developed to show how Just Culture works at Luton, showing all aspects of a ground handling incident, from the event and the person's decision to report it, to the investigation and finally to the change to the procedure that contributed to the event and, last but not least, to the person being commended by his manager for making the report. The event and the procedure change are real. The video shows that it is safe to report, and that reporting can lead to real safety improvement.
A final question must be addressed by this paper: Does Just Culture work? In the most recent safety survey at LTN, unreported events -i.e. ground handling incidents which could have gone unreported -were down by 57%, and incident reporting overall was up by b https://www.bainessimmons.com/aviation-consulting-services/smarrt-tools/fair-system/ c https://www.mindtools.com/pages/article/newTMC_5W.htm 41%. At the same time, five of the six top safety incident KPIs for LTN were down by 30% or more.
Just Culture is not simply a 'nice-to-have', it is necessary, and has to be reality rather than simply words on paper. The work at the Luton Stack shows that companies can work together to create a fairer system, and one where learning takes precedence. As was said at one of the meetings: You can either blame or learn -you can't do both.
The Safety Stack approach has now been applied to a second regional airport in the UK, and in their inaugural meeting they opted to focus on developing a Just Culture framework as a way of securing a stronger safety and learning culture, and a third (international) airport is about to start its airport-wide safety culture survey, in order to develop their own 'Safety Stack.'