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

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.

RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 Just culture “A culture in which front line operators are not punished for actions or decisions that are commensurate with their experience and training, 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 “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.

MEMBANGUN JUST CULTURE RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 MEMBANGUN JUST CULTURE 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. 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 kerja.

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

Key element: Information ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Key element: Information Concept of Safe Culture “Just Culture” vs “No Blame Culture” The Public Interest

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

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

Safety Management Systems ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 INFORMATION Key element of Safety Management Systems Without information reporting, collection and sharing…

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.

IMPLEMENTASI JUST CULTURE 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.1 2009, 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.

SAFE CULTURE Reporting culture Informed culture Just culture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 SAFE CULTURE Prof. James Reason Reporting culture Informed culture Just culture

SAFE CULTURE Informed culture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 SAFE CULTURE Prof. James Reason … 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 Informed culture

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

SAFE CULTURE Just culture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 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”. Just culture

Just Culture Honest Mistakes Zero tolerance Blame Free Gross RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 Just Culture Honest Mistakes Gross negligence Gross negligence Criminal offences Omissions Slips Lapses Mistakes Violations Slips Lapses Criminal offences Omissions Mistakes Violations Errors: 1) unintentional deviations from planned and desired actions: - slips (memory errors) - lapses (attentional errors); 2) deficiencies or failures in the judgemental and/or inferential processes which may generate an incorrect goal or may lead to the failure of the selected goal (mistakes). Violations: deliberate, but not necessarily reprehensible, deviations from those practices deemed necessary (by engineers, managers and regulatory agencies) to maintain the safe operation of potentially hazardous system (Reason, 1990). From these definitions it results that while slips, lapses and mistakes can be associated with individual cognitive processes and may be affected by individual internal aspects, such as personality and attitudes, that are always difficult to formalise, violations must be identified in relation to a socio-technical context which affects procedures, behavioural attitudes, practises, etc. Deliberate Unintentional Zero tolerance Blame Free

RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 The Public Interest Legal regimes should be set up with the aim of protecting 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 The ANSPs Interest Offer the best and safest service to their customer… And to earn money from that (if private)

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

SAFETY MANAGEMENT Reporting culture Informed culture Just culture RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 SAFETY MANAGEMENT Reporting culture Informed culture Just culture

RAKOR KOMUNIKASI PENERBANGAN and Air Traffic Services Safety Management Seminar BANDUNG, 21 – 23 NOVEMBER 2011 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.

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