Shifting to a Just Culture

Annie Gilbert from the Civil Aviation Authority describes the work of a joint CAA/industry task force which is targeting the seven areas which carry the highest risk in commercial aviation at airports











The UK has an impressive safety record of which the industry is rightly proud, but we can always strive to be better. While regulators have an important safety oversight role, individual operators ultimately have prime responsibility for managing their safety risk. Collaboration is the key.

In the UK, the Civil Aviation Authority is committed to driving improved safety performances across all sectors of the industry, through committed partnerships with key organisations. This approach has lead to the identification of seven areas which carry the highest risk in commercial aviation – dubbed the Significant Seven. Ground handling takes its place as one of the Seven alongside aircraft loss of control; runway excursion; controlled flight into terrain; runway incursion; airborne conflict; and, fire. For each of these areas, a joint CAA/industry task force has been created to study the safety issue in-depth and make recommendations on how their risk could be managed.

Low incident reporting

One thing to emerge from the work of the Ground Handling Operations Safety Team (GHOST) – a joint CAA/industry initiative tasked with tackling safety issues on airport aprons – was the low incident reporting rates by air-side workers. Ground service providers were brought into the CAA’s Mandatory Occurrence Reporting (MOR) scheme in 2007, effectively placing a legal obligation on maintainance and ground handling organisations to report safety incidents to the regulator. Despite this, reporting levels amongst personnel on the ramp remained much lower than for airline personnel. GHOST highlighted a culture amongst ground handling that tended to apportion blame and discouraged open reporting of incidents. This was an issue that was well known and well documented within safety investigations, and appeared to be accepted practice, not just in the UK but worldwide.

The CAA’s MOR database has been up and running for over thirty years and now contains details of hundreds of thousands of incidents, from minor technical and mechanical failures to fatal accidents. Around 10,000 new incidents are logged every year. The information that can be extracted from the database proves invaluable in plotting risks and trends, allowing operators to take action before a serious incident occurs. It is vital that ground handling crew, engineers, baggage handlers, dispatchers and drivers understand that the sole objective of the reporting of safety events is to prevent further accidents and incidents through the improved collection and sharing of safety information. It is not to attribute blame or liability.

Evidence shows that ground handling events likely to cause the greatest harm to aircraft safety are loading errors and serious collisions between vehicles and aircraft, with resulting damage that remains undetected prior to flight. It is very important that these incidents are properly logged.

To encourage ground service providers to report safety events, GHOST has collectively developed a Just Culture statement, which most members have now signed up to as an aspiration. It is currently promoting this message around UK airports. It states:

Just Culture is a culture that is fair and encourages open reporting of accidents and incidents. However, deliberate harm and wilful damaging behaviour is not tolerated. Everyone is supported in the reporting of accidents and incidents.

To assist those operators that have already signed up to the statement, the CAA along with members of GHOST have created an ‘off the shelf’ Just Culture campaign to raise awareness of the concept amongst airport staff and their stakeholders. This collaborative campaign was initially rolled out at London City Airport in June this year and has already proved a success. An ‘open day’ at the airport encouraged all air-side workers to engage informally with CAA safety experts and to learn about the concept of Just Culture and the importance of open reporting. Briefing materials are now freely available and posters prominently displayed in crew rest areas and company offices. The campaign is moving on with further launch events planned over the next six months. GHOST is planning to roll out the campaign to a further ten airports over the coming months.

Sharing knowledge

Open reporting should, of course, be an essential component of any operator’s Safety Management System. Risks can only be identified and managed if knowledge is shared. This sharing and reporting culture must pervade an organisation. Every member of staff, from the boardroom to the ramp must buy-in to this culture. Open reporting, ultimately, helps all parties involved in the aircraft turn-around process appreciate and understand where the risks are within the air-side environment.

The big challenge for the industry as aviation continues to grow is to identify ways to improve safety. This challenge can only be met by better understanding the past to help us predict the future. This is no easy task and new business practices are being developed to ensure this is achieved as effectively as possible. We are all in the same industry and have shared objectives and aspirations. We must work together to ensure commercial aviation is as safe as it possibly can be.

For more information on the Just Culture campaign contact learn more about the work of GHOST visit


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