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SLAMET MUJIYONO,S.Sos IACA TRAINING DEVELOPMENT DEPT. JUST CULTURE RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG,

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Presentasi berjudul: "SLAMET MUJIYONO,S.Sos IACA TRAINING DEVELOPMENT DEPT. JUST CULTURE RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG,"— Transcript presentasi:

1 SLAMET MUJIYONO,S.Sos IACA TRAINING DEVELOPMENT DEPT. JUST CULTURE RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

2 RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 apaan sih yang dimaksud JUST CULTURE…??? Jawabannya muacem-macem boss.. istilah Just Culture dipakai oleh ICAO dan industri penerbangan untuk membiasakan orang-orang tidak disalahkan atas kekeliruan yang dikerjakan melainkan dituntut untuk bertanggung jawab atas tindakannya, belajar dari kesalahan sendiri dan kesalahan orang lain.

3 “A culture in which front line operators are not punished for actions or decisions that are commensurate with their experience and training, Justculture but also a culture in which violations and wilful destructive acts by front line operators or others are not tolerated” RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

4 RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 “A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated” Just Culture memperlakukan manusia dengan adil dan mengakui bahwa manusia bisa berbuat salah, kesalahan yang benar-benar tidak disengaja merupakan hal yang wajar. Tidak langsung memberikan judgement bahwa tindakan dan keputusan buruk yang diambil dari seorang ATC merupakan kesalahan dan harus dihukum. Namun demikian Just Culture juga tidak memberikan toleransi terhadap kecerobohan dan kesengajaan (pelanggaran murni) yang mengakibatkan kesalahan berulang sehingga membahayakan safety.

5 RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 MEMBANGUN JUST CULTURE Pertama, kebijakan tentang pelaporan yang bebas dan jujur (free and frank reporting system) yang harus dibangun dengan komitmen kuat seluruh pimpinan organisasi. Sistem ini harus non punitive yakni seseorang tidak dihukum karena membuat laporan, termasuk laporan yang melibatkan dirinya. Pada situasi dan kondisi tertentu dia bahkan patut mendapat apresiasi. Kedua, kebijakan tentang batasan perilaku yang bisa diterima dan tidak bisa diterima. Batas antara hal yang harus dilakukan (do) dan yang tidak boleh dilakukan (don’t) harus jelas. Daftar ‘‘halal-haram ‘‘ ini bertujuan menghancurkan norma ‘sesat ‘ yang mengurat akar dalam kelompok ker ja. Ketiga, kebijakan tentang penerapan disiplin atau Disciplinary Policy yakni peraturan atau kebijakan tentang kadar atau tingkat hukuman. Dalam menjatuhkan hukuman harus mempertimbangkan berbagai faktor, termasuk sengaja atau tidaknya suatu perbuatan.

6 RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 Salah satu kunci sukses dalam mengimplementasikan Safety Regulation adalahpenerapan prinsip Just Culture, yaitu bagaimana mengelola “blame” dan “punishment”. Kebenaran mutlak hanyalah milik Allah Al – Haq, yang salah adalah produk manusia. Kalau ada yang salah mohon diingatkan. Silahkan berkomentar demi kemajuan kita bersama.

7  Key element: Information ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, September 2005  Concept of Safe Culture  “Just Culture” vs “No Blame Culture”  The Public Interest

8 Concept of Just Culture MAIN ELEMENTS: Gross negligence, willful violations and destructive acts Actions, omissions and decisions expected from someone with your level of training and experience Not tolerated Not prosecuted BUT WHO ASSESSES AND DETERMINES THIS?

9 Concept of Just Culture –Objectives: To provide increase in reporting Not to justify absence of reporting –Evolved from punitive-free reporting, blame free reporting To achieve a balance between interests of Safety (and protection of Safety Information) while allowing proper Administration of Justice

10 INFORMATION ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, September 2005 Key element of Without information reporting, collection and sharing… Safety Management Systems

11 RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 “A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated” Just Culture memperlakukan manusia dengan adil dan mengakui bahwa manusia bisa berbuat salah, kesalahan yang benar-benar tidak disengaja merupakan hal yang wajar. Tidak langsung memberikan judgement bahwa tindakan dan keputusan buruk yang diambil dari seorang ATC merupakan kesalahan dan harus dihukum. Namun demikian Just Culture juga tidak memberikan toleransi terhadap kecerobohan dan kesengajaan (pelanggaran murni) yang mengakibatkan kesalahan berulang sehingga membahayakan safety.

12 RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 IMPLEMENTASI JUST CULTURE 1. Melihat kembali dan meng-implementasi-kan mana saja regulasi, struktur dan prosedur yang bisa segera dilaksanakan, baik yang sifatnya Lokal (SOP, Skep Direktur, dll), Nasional (UU no , CASR, dll) dan Internasional (Doc. ICAO, Annexes, dll) 2. Tidak hanya fokus pada masalah legal formal regulasi yang ada, melainkan juga melakukan dialog/ seminar-seminar safety antara pihak-pihak yang terkait( regulator, management ANSP, ATC), membangun kepercayaan dan komunikasi, serta melaksanakan training-training yang recomended. 3. Menghormati peran dan tanggung jawab masing-masing pihak 4. Melakukan pendekatan kolaborasi dari semua pihak terkait 5. Menggunakan tehnik dan pengalaman terbaik 6. ATC melaporkan segala sesuatu yang menyangkut safety, dan management menngelola laporan yang diterima sebagai aset dalam meningkatkan safety.

13 SAFE CULTURE Prof. James Reason Informedculture Justculture Reportingculture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

14 SAFE CULTURE Prof. James Reason Informedculture  … is one that knows where the ‘edge’ is without having to fall over it first  … is preoccupied with the possibility of failure and works continuously to become more resilient to its operational hazards RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

15 SAFE CULTURE Prof. James Reason  An informed culture depends on PEOPLE reporting near misses, errors and incidents, Reportingculture  PEOPLE owning a “reporting culture” RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

16 SAFE CULTURE Prof. James Reason  But people won’t report if they don’t trust the system,  they certainly won’t report if they are disciplined or, worse, prosecuted, because of what they report.  Thence, a reporting culture can only grow from a “just culture”. Justculture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

17 GrossnegligenceCriminaloffences Omissions SlipsLapses MistakesViolations UnintentionalDeliberateDeliberate Honest Mistakes Zero tolerance BlameFree Just Culture GrossnegligenceCriminaloffences OmissionsSlipsLapsesMistakesViolations RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

18 Legal regimes should be set up with the aim of protecting the public interest. The Public Interest In relation to transport, we assume that the public interest be to travel maintaining the system at its safest level RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

19 Offer the best and safest service to their customer… The ANSPs Interest And to earn money from that (if private) RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

20 Law Makers The Danish example - Mutual Trust Public Prosecutor Aeronautical Organisations (Regulator, ANSP, ATCOs Association) L RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

21 SAFETY MANAGEMENT Justculture Reportingculture Informedculture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

22 CONCLUSIONS The legal world still holds the view that the system is inherently safe and that the humans are the main threat to that safety... while the aviation industry recognises the central role of humans in making the system work safely, although they are subject to be involved in occurrences. RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011

23 Slamet Mujiyono Indonesia Aeronautical Communication Association Uncontrolled Airspace & Aerodrome Safety Representative RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011


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