We Need a Just Culture at JFK

8 03 2010

JFK airport is finally in the news, again, for something other than delays or a crash. It managed to make the headlines after a controller let his young son repeat instructions on frequency to departing aircraft, which is something that both Don Brown, of Get The Flick, and Rob Mark, of JetWhine, feel posed no signifiant threat to airport operations. Don is a retired Atlanta Center controller with 25 years under his belt, including time as the union safety representative. Rob is a reputable consultant with just as much to say about piloting and controlling as he has experience doing each. I trust their judgement and think they deserve a little more than just a fleeting glimpse if you’re looking for something to read.


The argument against firing or suspending the controller and his supervisor seems to center around the fact that this is an isolated incident (I’m pretty sure there’s no underground, grass-roots effort by controllers to have their children key the mic until they can negotiate a better contract). But like any other recent problem with the aviation industry, the dilemma is more systemic and chronic than localized and short-term. The safety culture of the FAA is suffering at the hand of flawed public perception and higher-ups who are feeling the squeeze from people who can’t see the human fallibility in occurrences like this.

An organizational culture is a set of behavioral norms (“the way we do things around here”, says Reason). It lies at the intersection of the way people feel (shared values and beliefs) and how the system operates (structure and control). Sometimes with this there is a tense relationship between the top and the bottom of the hierarchy, which is why we’re seeing a lot of talk about how to develop an effective safety culture that can dampen the likelihood of additional risks popping up because people are not on the same page. An informed safety culture is generally considered to have four sub-cultures: a reporting culture that encourages honest disclosure; a flexible culture that can flatten the hierarchy and grant autonomy to people at the sharp-end; a learning culture that is proactive and competent in drawing smart conclusions; and a just culture that fosters trust and bolsters the other three subcultures while still drawing a line somewhere.

Just Culture is such an important, yet nebulous idea that it warranted a book by Dr. Sidney Dekker, a 737NG first officer and professor of human factors and flight safety at Lund University School of Aviation in Sweden. His book is not about diversity in Queens, but rather “Balancing Safety and Accountability” and how easily our society (or an organization, or the FAA) can shoot itself in the foot when it straddles the line between pragmatic and procedural reactions. Should the JFK controller be punished simply because he did something that is frowned upon? Or should he be punished only if there is something legitimate and valuable to be gained from his termination? I don’t even know if letting someone else speak over the radio is explicitly prohibited in the controller’s book of “Thou Shalt”.


In this instance, a smart and just culture would weigh the pros and cons of going after the controller by asking questions like “what is the informed community saying?” and “how will our decision impact our relationship with our workers?”. Before the pages in his book are even numbered with numbers (it’s on xii), Dr. Dekker says that “Unjust responses to failure…are not about bad performance. They are about bad relationships”.

No good parent would send their kid to his room for doing something that was neither bad nor against what they had told them to do. When I was younger, I was only ever punished for beating up my sister (now I just do it without getting punished). But mom and dad never used my middle name when I forgot to save some money during the week.

So maybe, instead of rationalizing the punishment, we need to reason with reality and develop professional tolerances that encourage cooperation for when the system really demands it. Severely punishing the JFK controller for something more dumb and petty than violent and egregious can leave the brotherhood of controllers bitter and resentful towards the system in which they work.

And who wants to be safe when you’re too busy being bitter and resentful?

Brian

P.S. – “Just Culture” was in the cockpit of US1549. Captain Sullenberger was reading it during his trip when he landed in the Hudson. He was given another copy – as well as the key to New York City – by Mayor Bloomberg.

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