Read Time 10 mins
06/06/2023
The Life Jacket Incident: A Crucial Lesson in Fostering a Just Culture in Aviation
Let me begin this discussion with a striking incident that took place at an airport serving the North Sea oil rigs.
A young ramp worker was assigned to stow spare life jackets in the hold of a helicopter, bound for a fully booked return journey. In the flurry of activity, one life jacket fell from his hands onto the ramp where a vehicle promptly drove over it. Fearful of his manager's reaction - a figure known for his strict demeanor - the young worker opted to say nothing, secretly stowing the damaged life jacket in the hold.
As the helicopter was poised to take off, guilt and concern gnawed at the worker. The potential danger of a faulty life jacket was too grave to ignore. So, he took a deep breath and told the helicopter captain about the accident.
Commended for his honesty by the captain, the life jacket was promptly replaced, averting any potential danger. However, this incident serves as a glaring example of an environment where the fear of retribution stifled open reporting. Had the young man's manager fostered a better 'just culture', this near-miss could have been resolved far sooner.
So how can leaders create a 'just culture' where individuals feel secure to report their own mistakes without fear? Let's explore...
Introduction
I am a seasoned aviation professional, having spent three decades in the industry, with twenty-five of those years dedicated to airline operations. Over the years, I have donned various hats, but what remained constant was my relentless pursuit of safety in all facets of my work. One philosophy that has always been at the core of my approach to safety is the concept of a "just culture".
In manned aviation, a "just culture" is not just a notion; it is the cornerstone that upholds our commitment to safety. This culture facilitates open and honest reporting of mistakes or incidents, free from the fear of retribution or unwarranted punishment. It is an environment that encourages learning from our errors and prevents them from recurring. This culture does not condone negligent actions but instead promotes responsibility, learning and overall safety enhancement.
Over the past few years, my career trajectory shifted towards Unmanned Aircraft Systems (UAS), commonly referred to as drones. It's a field that is burgeoning at a rapid pace, bringing with it a host of novel opportunities and challenges. My experiences in manned aviation made one thing clear: the same principles of a just culture and open reporting that have been fundamental to the safety of traditional aviation are critically needed in the realm of UAS operations as well.
This crossroads, where my experience in manned aviation meets my current immersion in the UAS world, is the impetus for this blog post. It is my belief that the successful adoption and implementation of a just culture within UAS/drone operations will greatly enhance safety while fostering an atmosphere of mutual respect, learning and continuous improvement. The focus of this discussion is on the importance of this philosophy and how we, as a collective, can contribute towards establishing it as a standard in the UAS/drone industry.
The Importance of Open Reporting and Just Culture in Aviation
In the context of aviation safety, a "just culture" represents an environment where mistakes and errors aren't suppressed but reported openly and honestly. It's about balancing safety and accountability, where operators are encouraged to learn from their errors and contribute to the collective understanding of risk while still being held accountable for actions that are egregiously reckless or negligent.
During my tenure in manned aviation, I can recall numerous instances where the principles of open reporting and a just culture have averted potential hazards. One instance that comes to mind involved an experienced pilot who unintentionally neglected a pre-flight equipment check due to a heavy workload. Recognising this error, the pilot reported the oversight without delay. Because of the open reporting atmosphere and a just culture that was well-inculcated, the mistake was addressed and the flight departed safely after a slight delay. Instead of reprimanding the pilot, the event was used as an opportunity to reinforce the importance of procedural adherence and to review workload management strategies, benefiting the entire team.
The fundamental principle of self-reporting without fear of retribution is a pillar of the just culture in aviation. By encouraging individuals to report their errors, we can turn potential failures into learning opportunities, thereby improving safety. This philosophy has been an instrumental factor in shaping the excellent safety record in manned aviation. It is a mindset that needs to be embraced wholeheartedly as we forge ahead into the frontier of UAS/drone operations.
The Current State of UAS/Drone Safety Culture
As I've moved into the UAS/drone world, I've had the chance to observe its safety culture firsthand. The UAS industry is diverse, comprising hobbyist pilots, commercial operators and everything in between. This diversity brings a wide range of attitudes towards safety and operational rules, making for a complex picture.
Unfortunately, there are instances where some operators openly disregard regulations. These operators may boast about flying beyond visual line of sight, exceeding altitude restrictions or operating in restricted areas. Such behavior not only poses a safety risk but also has the potential to harm the reputation of the entire industry. The public's perception of UAS/drone operations can be significantly tainted by these reckless actions, casting a shadow over the many operators who adhere to the rules and respect the importance of safety.
However, it's crucial to note that these rule-breakers are not representative of the entire community. Many UAS/drone operators are highly professional, responsible and safety-conscious. They follow the rules, take their responsibilities seriously and strive for continuous improvement.
One encouraging trend is the sharing of personal experiences, both positive and negative, within the community. On various social platforms, operators are beginning to share their stories of mistakes, mishaps and lessons learned. For example, a drone pilot once shared a story about losing control due to strong winds and how they managed to regain control eventually. The pilot shared their mistake to remind others of the importance of thoroughly checking weather conditions before flight.
These examples are invaluable for learning and collectively improving safety in the UAS/drone world. It demonstrates the humility and courage to admit when we've erred and shows a commitment to learning from these experiences. This behavior should not only be encouraged but celebrated, as it forms the foundation of a just culture, where we can all learn and improve together.
Challenges Faced by the UAS/Drone Industry
The UAS/drone industry, while rich with opportunities, is also fraught with unique challenges. The broad range of operator experience is one significant challenge. From seasoned pilots familiar with manned aviation, moving to unmanned systems, to hobbyists with limited aviation knowledge, the skill spectrum is vast. Ensuring consistent safety standards across this diverse group is a significant task.
Technology is advancing at an incredible pace, with new systems, capabilities and applications for drones being introduced almost daily. While these advancements provide exciting new possibilities, they also create an environment where the pace of change can sometimes outstrip established safety norms and practices, necessitating a continuous review and update of safety standards.
The regulatory environment is another challenge. Regulations are often trying to catch up with the technological advancements and varied uses of drones, creating a dynamic and complex environment that can be difficult for operators to navigate. The need for global harmonisation of regulations is also apparent as UAS operations continue to become more ubiquitous and cross-border.
Public perception is yet another hurdle. Drones have sometimes been associated with privacy infringements, unauthorised surveillance and nuisances. Incidents of reckless behavior, even if isolated, can feed into these perceptions, undermining the public's trust in the industry.
Another discouraging factor is the criticism faced by operators who do share their mistakes. Instead of constructive feedback, these operators are often met with negative comments and blame, which discourages not only them but also others from sharing their experiences. This criticism goes against the principles of a just culture and hampers the collective learning that can be derived from openly discussing these incidents.
Addressing these challenges will require a collective effort from everyone involved in the industry - from individual operators to organisations and regulatory bodies. Promoting a just culture, where mistakes can be shared and learned from without fear of undue retribution, is a crucial part of the solution. This culture can help us navigate these challenges successfully, making UAS/drone operations safer and more accepted by the wider public.
The Need for a "Just Culture" in UAS/Drone Operations
As we navigate the myriad challenges faced by the UAS/drone industry, it becomes increasingly evident that the principles of a "just culture" are not just applicable but are fundamentally necessary for this field.
A just culture in UAS/drone operations can significantly improve safety standards. It encourages openness and transparency, prompting operators to report their mistakes without fear of undue punishment. This self-reporting leads to a collective understanding of what went wrong and why, allowing everyone in the community to learn from each incident and take preventive measures to avoid recurrence. This continuous learning loop contributes to enhanced safety practices, minimising risks and improving overall operational safety.
The concept of a just culture also plays a vital role in improving the public image of the UAS/drone industry. The proactive adoption of a just culture sends a powerful message to the public about the industry's commitment to safety and continuous improvement. It signals that the industry is not complacent about its challenges but instead is actively working to learn and improve.
Moreover, when operators are transparent about their mistakes and the steps taken to rectify and learn from them, it helps build public trust. It shows that the industry is responsible, accountable and focused on safety above all else.
Therefore, the need for a just culture in UAS/drone operations is of paramount importance. By creating an environment that fosters learning from mistakes rather than fearing them, we can collectively raise safety standards, promote continuous improvement and cultivate a positive public image - factors that are integral for the future growth and success of the industry.
Steps to Promote a Just Culture in UAS/Drone Operations
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Individual Operators: First and foremost, operators must be willing to adopt a self-reporting mindset. This includes acknowledging mistakes, reporting them transparently and willingly participating in discussions about how to learn and improve from these incidents. Self-reflection and continuous learning should be integral components of every operator's approach to their role.
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Organisations: Companies operating in the UAS/drone industry have a critical role to play. They must cultivate an organisational culture that encourages openness, learning and accountability. This includes creating clear policies for reporting and learning from errors and ensuring that punitive actions are not the default response to mistakes. Emphasising that safety is above all else and that the organisation supports and appreciates openness can go a long way in promoting a just culture.
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Regulators: Regulatory bodies can promote a just culture by providing clear guidelines and frameworks for reporting incidents and mistakes. They can also emphasise the importance of a just culture in their communications, policies and regulations. Establishing non-punitive reporting systems can encourage more operators to come forward with their mistakes and experiences.
Leadership has a central role in promoting a just culture. Leaders set the tone for an organisation's culture. By demonstrating through their actions and words that they value transparency, learning and continuous improvement over blame and punishment, they can greatly influence the behaviors of their teams.
Finally, appropriate training and safety education are crucial. Operators should be trained not only in the technical aspects of operating UAS/drones but also in the principles of a just culture. They should understand the value of self-reporting, the process of learning from mistakes and how these contribute to the overall safety and success of UAS/drone operations.
Promoting a just culture in UAS/drone operations is a journey rather than a destination. It requires ongoing effort, learning and adjustment. But with the shared commitment of everyone involved, we can foster a culture that enhances safety, builds trust and ensures the future success of the industry.
Fostering a Peer-Supportive Environment in UAS/Drone Operations
One crucial aspect of promoting a just culture in the UAS/drone industry that deserves a spotlight is the role of peers - both fellow operators and hobbyists alike. The social and professional networks within this community can significantly impact the efficacy of open reporting and the adoption of a just culture.
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Encouraging Open Reporting: Peers should be supportive when an operator comes forward with their mistakes. Instead of criticising the reporter, we should appreciate their courage and willingness to share their experiences for the collective good. Constructive discussions around the incident, focusing on lessons learned and ways to avoid similar mistakes in the future, should be the norm. These positive interactions will reinforce the importance of open reporting and encourage others to follow suit.
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Promoting a Learning Mindset: Peers should foster an environment that encourages learning from one another's experiences. Sharing knowledge and learning from each other's mistakes is a powerful way to enhance safety in our operations. Peers can contribute by asking insightful questions, sharing their own experiences and solutions and encouraging others to do the same.
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Discouraging Rule-Breaking: On the flip side, peers should discourage actions that flout rules and disregard safety norms. Such behavior should not be celebrated or encouraged. Instead, the focus should be on promoting responsible and safe UAS/drone operations.
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Positive Online Interaction: Given the prevalence of online platforms in sharing experiences and learning in the UAS/drone community, it's crucial that these spaces are used positively. Encouraging open reporting, constructive feedback and shared learning on these platforms can significantly contribute to promoting a just culture.
The path towards a just culture in UAS/drone operations is a collective journey. Every member of this community, from operators to hobbyists, from leaders to peers, plays a pivotal role. By encouraging open reporting, promoting a learning mindset and supporting each other, we can collectively foster a culture that prioritises safety, responsibility and continuous improvement.
Conclusion
The impact of a just culture in the UAS/drone industry cannot be understated. By promoting open reporting, encouraging learning from mistakes and prioritising safety above all else, we can significantly enhance operational safety and public trust in the sector.
Everyone reading this, particularly those directly involved in the UAS/drone industry, has a role to play in fostering this culture. It's essential to remember that safety is a shared responsibility. We all contribute to the overall safety culture - our attitudes, behaviors and actions all count. By embracing a just culture, we contribute to the maturation and growth of the UAS/drone sector, helping it realise its full potential while ensuring safety remains our top priority.
Call to Action
If you're part of this dynamic and exciting industry, I encourage you to share this post with your peers. Let's spread the word about the importance of a just culture and the role we all can play in promoting it.
I invite you to share your thoughts, experiences and ideas on fostering a just culture in UAS/drone operations. How do you promote open reporting and a safety-first culture in your own operations? Have you witnessed the positive impacts of a just culture? Your insights can be a valuable part of this important conversation.
Lastly, let's all pledge to be more understanding and supportive of those who have the courage to share their mistakes. It takes bravery to admit when we've erred and those who do so deserve our respect and support. Their willingness to share their experiences can be a valuable lesson for all of us, contributing to our collective growth and improvement.
Let's continue to strive for safety, learn from each other and foster a just culture in the UAS/drone industry. Together, we can make a significant positive difference.