An Cosantóir

45 training, but where gross negligence, wilful violations and destructive acts are not tolerated. The Irish Air Corps promotes a Just Culture for all personnel. It is provided for through the Flight Safety Regulation Manual as issued by the General Officer Commanding, Air Corps, Director of Military Aviation. A Just Culture is vital to the Air Corps Flight Safety Reporting System. It is certainly true to say that having a Just Culture in regulation is only the first step. A Just Culture is one which must be fostered and developed over many years. It must be supported by actions consistent with the written policy. The term 'Just Culture' was first presented by Dr James Reason in 1997, it is employed in both civil and military aviation around the world. Recently other industries and organisations such as healthcare have sought to implement a Just Culture on foot of the positive impact it has had in Aviation Safety. Organisational Era (1990s to 2010s) Following on from the Human Factors Era, greater consideration was given to the role that the wider organisation had in accident/incident reports. This sought to widen the scope of safety investigations to not just the person at the front end and their actions, but examine the preconditions, supervision and organisational factors which may have contributed to the accident/incident. This era is perhaps best characterised by the 'Swiss Cheese Model'. This model recognises that in complex operations such as aviation, there are multiple barriers/defences. In order for a hazard to result in an accident/incident, multiple layers of defence must be breached. The final slice or defence is the person/operator at the front end. To only view their actions in isolation does not provide a full picture on what happened the other defences, to allow the hazard permeate to the last line of defence. The holes in the Swiss Cheese Model represent the gaps which can appear in defences. These gaps are dynamic and are constantly changing in size dependent on the operation. A functional SMS system will constantly monitor these gaps and strive to implement measures to eliminate or minimise them. The model is a nice way of conveying the concept of the organisational era, however it does not reflect the reality of complex nature of interactions and interdependency between the various components of the system which is aviation. Accident and incident reports are a more effective way of conveying the true complexities involved. Systemic Era (2010s to Present) In recent years the organisational era has been replaced with the systemic era. This has built on the concept of the organisational era by expanding the considerations to the role of external agencies, design manufacturer, certification, oversight and regulation. It recognises that the defences in the 'Swiss Cheese Model' can be impacted not only by the internal workings of the organisation A CENTURY OF FLIGHT AND THE EVOLUTION OF AVIATION SAFETY as 'Crew Resource Management'. The aim of this training was to address how humans within the aviation system interacted with one another. This training initially aimed at pilots but now encompassing all crew, is used across aviation to this day and is conducted annually by Air Corps Personnel. The focus on human factors continued with an examination of organisational culture and how this was impacting on human performance and safety management. It was found that aviation was operating to a punitive culture of blame to address mistakes and errors. In a military setting, this could result in disciplinary action or court martial, in civil settings it could result in a person losing their job. The net effect of this punitive culture was a lack of willingness for people within the system to self-report errors/incidents. This lack of reporting posed a real problem for aviation safety. Safety reports are the lifeblood of a Safety Management System. Safety reports give data on how the safety management system is performing. When someone self-reports and shares an error/occurrence it effectively means that they are identifying a potential hazard (perhaps one the organisation has not yet considered) or it may show that a safety barrier currently being used, is not as effective as the organisation may have thought. By addressing the hazard/barrier the overall system safety can be improved and hopefully prevent a hazard developing into an incident or accident. To address this fear of reporting, the concept of a 'No Blame' culture was introduced. The idea being, if someone made a mistake but reported it, they would not be blamed. This would seem to address the issues outlined above, but it had an unintended consequence as this concept created opportunity for personnel within the system to operate in a culture where disregard for rules, procedures and plans could be excused under a culture of 'No Blame'. To manage this unintended consequence the Just Culture concept was developed. A Just Culture, is one in which personnel who report are not punished for actions, omissions or decisions taken by them commensurate with their experience and Blame and No Blame Cultures Dr James Reason's 'Swiss Cheese Model'

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