Leading meaningful discussion on the issues and challenges that will shape the aviation industry’s future.
The aviation industry as a whole, broadly accepts the premise ‘to err is human’. In western based countries, this has resulted in the industry advocating a system of safety that divorces human error from accountability. This is more widely known as a ‘just culture’, where the overarching principle is to treat people fairly if they make mistakes, even if the mistakes lead to negative outcomes. Such a perspective on human error is reflected more broadly in the shift from Safety-I, where the focus was understanding what went wrong, to Safety-II, where the focus is on understanding the system’s ability to succeed.
It can be argued, however, that this shift and focus is problematic, neglecting fundamental principles associated with human behaviour. Humans are central to the success and failure of all systems. Having a detailed understanding of why humans err, will ultimately result in improvements in safety. Such knowledge does not and should not be at odds with a mature safety system, where the focus is on improvements and not retribution. Therefore, this panel will discuss the latest research about human error, the link between motivation, punishment, reward and human error, and a retributive vs. a just safety culture.
UNSW Aviation has launched the first of many panel discussions that will engage industry and academia to come together to discuss and debate issues of common interest.
The topic for the first event focused on human error and a retributive versus a just safety culture. Professor Brett Molesworth (Head of School and Human Factors expert) moderated a panel that featured Captain Curtis Calabrese (United Airlines Pilots and UNSW Aviation Researcher), Mr David Chitty (Member for NSW Bar Association and UNSW Aviation Law Lecturer), Ms Louise Kirkwood (Senior Manager Aviation Psychology and Human Factors, Qantas), Captain Tony Lucas (A330 and Training and Checking Captain, President of Australian and International Air Pilots Association (AIPA)), and Dr Kevin McMurtrie (Senior Flying Operations Inspector, CASA).
The discussion held on Thursday 27 July ranged from identifying the legal ramifications of a just culture to the issues around the diverse perceptions and understanding of what constitutes a just culture in order to identify processes for improvement and whether just culture hinders or facilitates reporting and by extension, safety advances.
Some takeaways and food for thought from the panel discussion are:
Understanding of what just culture is varies greatly.
Perspectives vary depending on whether it comes from the victim, the offender, the lawmaker and the general population, and this is further varied by cultural and organisational differences.
It is important to understand that a just culture isn’t a consequence free environment. ICAO regulations expressly state that any form of corrective, remedial or preventative action by an agency or service provider is not to be considered as punitive if conducted under certain protocols. The expectation of ICAO is that remedy and corrective action is a normative part of safety management.
Just culture is really about the individual being held accountable for their behavioural choices, not the outcome.
Recurrent training to address behavioural choices is not punitive, and central to a just culture.
CASA advocates and operationalises just culture quite well, though it does not regulate it.
The key to creating a successful just culture is establishing a robust safety management system. This will help identification and reporting information, analysis and mitigation of risks from a safety point of view.
Professor and UNSW Aviation Head of School, Human Factors and Aviation Safety
Professor in Human Factors and Aviation Safety, holds a CPL with an advanced aerobatics rating and is a Registered Psychologist. Has a keen interest in understanding human behaviour in both normal and abnormal situations. Brett’s application of his knowledge and expertise extends beyond the aviation industry and includes other modes of transportation, such as road, as well as other high consequence industries, such as medicine.
United Airlines Pilot and UNSW Aviation Researcher
Captain Curtis Calabrese is a PhD candidate at UNSW Sydney. He is a former U.S. Navy reconnaissance pilot and accrued over 250 combat flight hours in the P-3 Orion and P-8 Poseidon. Following his military service, he became an Inspector for the Federal Aviation Administration, where he led the investigations of more than thirty significant aircraft accidents and countless incidents. Notably, he served as the Inspector-in-Charge for the fatal 2020 Calabasas, California helicopter accident which gained a worldwide audience. Curtis is a now a Boeing 737 Captain at United Airlines, a member of the Air Line Pilot Association Safety Committee, and serves as the Assistant Director of Operations at Skyways Charter, a private jet charter company headquartered in Florida.
Member for NSW Bar Association
Prior to being called to the NSW Bar in 2014, David held an Executive position with Qantas Airways Ltd as the Head of Compliance and Industry Relations (this position encompassed the International Operations Division which included; Flight Operations, Continuing Airworthiness and the Safety Department).
David also held a position within IATA on their Asian and North Asian Regional Co-ordination Group (policy development for Safety and Operations across the airline industry). David’s principal areas of practice at the Bar includes all aviation matters, Workplace Health and Safety within high-risk industries such as aviation, mining and oil exploration etc, international law and operational regulatory advice.
Senior Manager Aviation Psychology and Human Factors, Qantas
Louise’s career history includes working 30 years as a Psychologist (both within the Organisational and Clinical field). She has held various leadership roles where she has enjoyed executing and delivering major complex projects around culture change, job and organisational design, human risk management, selection and recruitment, health and wellbeing and crisis response.
Louise currently holds the position of Senior Manager Aviation Psychology and Human Factors across the Qantas Group of airlines and associated businesses. Within this position she leads the Av Psych, Human Factors and Fatigue teams. Louise has worked in all aspects of human performance from preventing human error to maximising human potential and organisation performance.
Before joining Qantas, Louise held various positions as a behavioural expert within management consulting and government organisations specialising in transformation and change, developing high performing teams and stress management. Louise is also a Senior Psychologist in the Army Reserve where she provides mental health support to military operations and has served in Bougainville, Solomon Is, East Timor, the Middle East and Afghanistan.
A330 and Training and Checking Captain, President of Australian and International Air Pilots Association (AIPA)
Tony grew up in the southern suburbs of Sydney and was educated at Endeavour High School graduating in 1988. Subsequent to high school Tony was employed at the Regent of Sydney in the security department whilst funding his Unrestricted Private Pilots License through the Scouts Air Activities Centre at Camden.
Tony was lucky enough to be selected as a Qantas Flying Training Scheme Level 1 Cadet in 1991 graduating in September 1992 before commencing employment with Qantas Airways as a Second Officer on B747-400 aircraft in January 1995.
In 1997 Tony completed First Officer promotional training on the B767 and then in 2006 completed a type transfer returning to the B747-400 as a First Officer. Tony was a Human Factors facilitator from 2004 to 2006.
In September 2008 Tony completed command training on B767 aircraft and was a Captain on that aircraft until it was retired from Qantas service at the end of 2014. In 2015 Tony spent a short time on the A380 as a First Officer before returning to Command on the A330 in late 2015. Tony completed his Check and Training Captain accreditation on the A330 in October 2016.
In 2004 Tony completed a Bachelor of Aviation through University of Western Sydney, a Certificate IV in Workplace Training and Assessment, and a Certificate IV in Business (Frontline Management).
A member of the Australian and International Pilots Association (AIPA) since joining Qantas in 1995, for a number of years in Tony coordinated the AIPA/ UNSW Mentoring program for aviation degree students pursuing the flying stream. Tony joined the AIPA Committee of Management in February 2021 and was appointed as AIPA’s President in February 2022.
External to Qantas, Tony served as an airman and officer in the Australian Air Force Cadets from 1990-2010 rising from Aircraftsman (AAFC) through to the rank of Wing Commander (AAFC) and holding the role of Officer Commanding Ground Training Wing.
Tony is married to Kayleen and they have three children aged 24 to 15. They attend an Anglican Church in Caringbah and reside in the southern suburbs of Sydney. Tony attends as many Sydney Swans matches as possible.
Senior Flying Operations Inspector, CASA
Kevin McMurtrie completed his PhD in 2021 with the School of Aviation at the University of NSW Sydney. Kevin’s research examines flight crew reporting behavior, trust, and confidence in just culture. Kevin is a Fellow of the Royal Aeronautical Society, has a 27-year career in Commercial Aviation, primarily in flight training as a Head of Operations and Flight Examiner. Kevin is currently a Senior Flying Operations Inspector at CASA and is presently technical lead for the SMS transition program under the new flight operations regulations. Kevin also facilitates the postgraduate SMS program at the UNSW School of Aviation.