a shift in - d2nvf92ef53i1o.cloudfront.net shift in safety... · a shift in “safety thinking ”...
TRANSCRIPT
A Shift In
“Safety Thinking”
Presented by: Jim Hein, ASI-FPM-MAS
Presented to: NBAA IA Renewal
October 21, 2013
Human Behavior
Safety Management
Series
Zero Violations is the “new standard”
2
Reasons for this presentation:
• Promote a generative safety culture.
• Promote a “zero violation” climate
• Promote a “Reporting Culture”
The Safety
Concept
Human Behavior
Safety Management
Series
4
Concept of safety
• What is safety
– Zero accidents (or serious incidents)?
– Freedom from danger or risks?
– Error avoidance
– Regulatory compliance?
– … ?
5
Concept of safety
• Safety is the state in which the risk of harm to
persons or property damage is reduced to, and
maintained at or below, an acceptable level through
a continuing process of hazard identification, risk
management and use of established safety
controls.
Ref: ICAO Doc 9859
reduced to
an acceptable level through
use of established safety
controls.
Safety is risk
Risk level
Acceptable risk level
Established safety controls
6
Concept of safety
Ref: ICAO Doc 9859
Risk level
Acceptable risk level
Established safety controls
• Combination of hazard consequences and frequency
• Risk level is unknown until hazards are analyzed
• Level established by the organization
• Done by a documented methodical process
• Policies, procedures, regulations, best practices …
7
Controls are mitigation
strategies designed to reduce
risk when “human factors”
negatively combine with what
we are doing.
• Policies
• Procedures
• Rules
• Regulations
• Best Practices
History of
“Safety-Think”
Human Behavior
Safety Management
Series
9
The evolution of safety thinking
TODAY 1950s TECHNICAL
FACTORS
1970s HUMAN
FACTORS TODAY
1990s ORGANIZATIONAL
FACTORS TODAY
2000s CULTURAL
FACTORS TODAY
Manufacturing, Operations, Maintenance, Design
Human Failures
Management, supervision, company policies
Behavioral Failures
Culture
Traits
Human Behavior
Safety Management
Series
11
Distinct culture sources • National culture encompasses the value system of
particular nations.
• Organizational/corporate culture differentiates the
values and behaviours of particular organizations
(e.g. government vs. private organizations).
• Professional culture differentiates the values and
behaviours of particular professional groups (e.g.
pilots, air traffic controllers, maintenance
engineers, aerodrome staff, etc.).
• Personal culture …. Differentiates the values and
behaviours of each individual for any given
circumstance.
No human endeavour is culture-free
12
Organizational/corporate culture
• Sets the boundaries for acceptable behaviour in the
workplace by establishing limits.
• Establishes acceptable risk levels.
• Provides a frame work for managerial and
employee decision-making
• Shapes acceptable procedures and practices.
13
Organizational Culture Attributes:
Hidden
Shouted
Shirked
Discouraged
Covered up
Crushed
Conflicted organization
Ignored
Tolerated
Boxed
Allowed
Merciful
Problematic
“Red tape” organization
Sought
Trained
Shared
Rewarded
Scrutinized
Welcomed
Reliable organization
Pathological Bureaucratic Generative
Information
Messengers
Responsibilities
Reports
Failures
New ideas
Resulting organization
Source: Ron Westrum
14
PATHOLOGICAL who cares as long as we’re not caught
REACTIVE Safety is important, we do a lot every
time we have an accident
CALCULATIVE we have systems in place to manage
all hazards
PROACTIVE we work on the problems that we still
find
GENERATIVE safety is how we do business
round here
Increasing Trust
Increasingly
informed
Range of organizational cultures
15
Culture Summary
• National
• Organizational
• Professional
• Personal
• Pathological
• Bureaucratic
• Proactive
• Generative
CULTURE TYPES CULTURE TRAITS
• Just
• Flexible
• Willing
GENERATIVE CULTURE TRAITS
• Learning
• Accountable
• Reporting
16
Personal culture
• Must comply with the limits established for
acceptable behaviour in the workplace.
• Must protect acceptable risk levels.
• Must believe in, support and utilize safety reporting
procedures and practices set by the Organizational
culture.
• Can highly influence behaviours within the
organizational culture (positively and negatively).
Errors Mistakes
and Lapses
Human Behavior
Safety Management
Series
18
Understanding human error
• Competent people commit errors.
• Errors are normal where humans and
technology interact.
• Human error is a contributing finding in
aviation occurrence investigations.
• Risk reduction strategies protect when
human errors occur.
Controls are mitigation strategies designed to reduce risk when
“human factors” negatively combine with what we are doing.
“Violations”
vs
“Mistakes”
Human Behavior
Safety Management
Series
20
Violation Definition
• Violations are deliberate and intentional deviations from policies, rules, procedures, instructions, regulations, and best practices developed to promote acceptable risk levels and efficient operations.
21
Violation Definition
• This should not be confused with the human condition of making mistakes.
• Human errors, mistakes and violations all result in “non-compliance”
• The difference is that
violations are preventable.
22
Understanding violations:
System output Maximum Minimum
Risk
High
Low
Safety space
Vio
lati
on
sp
ace
Exc
epti
on
al v
iola
tio
n s
pac
e
Incident
Accident
System’s production objective(s)
Acceptable
risk level
23
Rationalizations for Violation
• Expectation – Rule must be bent to get the job done
• Powerfulness – Ability, Experience, Judgement
• Opportunities – Optimization, Short cuts, Better, Quicker
• Planning – Poor advance preparation, working on the fly
Patrick T.W. Hudson, D. Parker, R. Lawton, (2005)
24
Why are Violations Dangerous?
• Violators assume they’re the only one
• Violators don’t tell anyone what they are doing
• Violations Increase risk levels to “unacceptable”
• Errors (slips, lapses, mistakes) are independent
of intention
• Violations combine with human errors to create
unacceptable or dangerous circumstances.
• Violation + Error = Death/Doom/Disaster
Managing Maintenance Error, James Reasons and Alan Hobbs
25
Tools for better
safety cultures
Human Behavior
Safety Management
27
Tools currently available
• Management Training
• SMS Training (SRM- SA)
• Root Cause Analysis Training
• LOSA
• HF Training
• Employee Reporting
Effective safety reporting – Five traits
Information
People are knowledgeable about the human, technical and
organizational factors that determine the safety of the system
as a whole.
Flexibility People can adapt reporting
when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing
information to quickly reach the appropriate decision-
making level .
Learning
People have the competence
to draw conclusions from
safety information systems
and the will to implement
major reforms.
Willingness
People are willing to
report their errors and
experiences.
Accountability
People are encouraged (and rewarded) for providing essential
safety-related information. However, there is a clear line that
differentiates between acceptable and unacceptable behaviour.
Effective safety reporting
Barriers to a
Zero Violation
Safety Climate
Human Behavior
Safety Management
Series
30
# 1 Barrier to ZV success
• People are afraid of
unknown
• Expectations based on past
experience
• Desire to “test” the system
• Looking for WIIFM
• Fear of losing job
• Fear of being outside of
comfort zone
• Fear of being out of control
• Perceived as a “turf” battle
• Feeling of inadequacy
– Lack of experience
– Lack of sufficient skills
• Lack of management
sponsorship
Resistance and Fear*
* Change Management, Chad Van Zandt, 2004
31
Change Resistance Antidotes:
• Training
• Coaching
• Support
• Reinforcement
• Communications
• Set Zero Violations as the minimum
“STANDARD”
* Change Management, Chad Van Zandt, 2004
Call to Action
Human Behavior
Safety Management
Series
Now is the time for a
“safety-think” shift
Begin by making Zero Violations
“The Standard”
33
34
Questions ???
FAASafety.gov
We Need Your
Help