AINsight: Just Culture—Are We There Yet?

 - November 22, 2019, 9:56 AM

A Boeing 747-400 attempting to take off during a typhoon crashes through construction equipment and barriers, killing 83 of the 179 people on board. Three days later, authorities declare “pilot error.” For the next two months, all three flight crewmembers—the captain, first officer, and relief pilot—are detained while prosecutors began building a case to pursue criminal manslaughter charges.

This event, nearly two decades ago, was the tragic crash of Singapore Airlines Flight 006 (SQ 006) in Taipei, Taiwan. A fiery crash, a massive loss of life, a rush to judgment, misplaced blame, and another attempt to criminalize an aviation accident were all outcomes of this event. It’s difficult to determine if the aftermath would be any different today.  

Since SQ 006, criminal proceedings following aviation accidents and incidents have been initiated in Brazil, France, Greece, India, Indonesia, Spain, Switzerland, and, most recently, Russia. These government “overreaches” are a clear threat to aviation safety.

In a recent editorial, Flight Safety Foundation president and CEO Dr. Hassan Shahidi said criminalization of aircraft accidents “can have a chilling effect on the flow of crucial safety information and have a long-term adverse impact on safety. Holding controllers, pilots, and aviation technicians criminally liable for honest mistakes ultimately threatens the safety of the traveling public.”

The primary objective of an investigation is to prevent future incidents and accidents. ICAO Annex 13–the global guide for aircraft accident and incident investigations—clearly states “it is not the purpose of an investigation to apportion blame or liability.” Yet today, many authorities around the world would rather seek retribution for an incident or accident than determine cause.

For example, earlier this year India’s DGCA suspended more than 40 pilots’ licenses for up to 12 months for perceived safety violations (non-alcohol related) without a full investigation or process. This heavy-handed approach stifles the spirit of openness and cooperation that is the foundation of any technical investigation and modern safety beliefs.

Unfortunately, the concept of applying a just safety culture in aviation is elusive. It’s truly a global clash—a conflict between blame and accountability. According to aviation safety expert James Reason, the components of a safety culture include just, reporting, learning, informed, and flexible cultures. A just culture is an atmosphere of trust where individuals are encouraged and sometimes rewarded for providing safety-related information.

A key principle of a just culture is the clear understanding of the difference between acceptable and unacceptable behavior. Defining what is acceptable or unacceptable is a trick. Who gets to decide?

The left side of this line allows for human error, omissions, and lapses, and accounts for other vulnerabilities in the system, whereas on the right side of the line are behaviors that are determined to be culpable such as intentional willful violations, reckless behavior, or criminal acts.

Back to SQ 006. Just days after the accident, Taiwan’s Civil Aeronautics Administration (CAA) director-general said the three pilots “must shoulder the responsibility.” Blaming the accident on pilot error made the pilots the scapegoats.

The claim of pilot error—more of a symptom than a cause—related to the aircraft attempting to take off from a closed runway. It was clear that blame would trump accountability. This claim of pilot error would be dismissive of the critical “what” and “why” of a major event; that’s how we learn.

In the end, a multitude of other issues were identified during the investigation: intense rainfall, low visibility, strong winds, communications, poor runway markings on the closed runway, a lack of ground surveillance radar, and runway lighting circuitry that lit both the active and closed runways. Just before midnight and amid a typhoon, “Cleared to take off on Runway 05L” were the instructions from ATC.

The crew rather than making the second right hand turn onto Runway 05L, made the first right onto a partially lit Runway 05R that was closed. Approximately 41-seconds after setting takeoff thrust, nearing rotation speed, the aircraft struck barricades and machinery, breaking into three major pieces. The middle section of the fuselage and wings exploded and were incinerated; most of the casualties were seated in this section. The rest is history.

Significant in many ways, case studies of SQ 006 introduced me to the idea of a systems approach to aviation safety and that the efforts of safety professionals are often eclipsed by overly aggressive judicial authorities. Human error that results in a runway incursion or excursion is an opportunity to learn and should not be punished.

Retribution against an individual for an honest mistake holds the potential to interfere with the prevention of future incidents or accidents. Motivation by fear will limit participation in change.

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached by email.