Achieving a Safety Culture in Achieving a Safety Culture in AviationAviation

Patrick HudsonLeiden University

ContentsContents

• Safety Management in aviation• Safety Culture - the added extra• The Evolution of Culture• Acquiring and maintaining a

Safety Culture• Conclusions

Aviation Safety ManagementAviation Safety Management• Aviation has traditionally been managed

from on high• Regulations (SARPs) have been classic

prescriptive regulation - Tell What To Do• Progress was based on response to accidents• Fear of the consequences has kept people

sharp• There were no requirements for processes• Aviation’s performance has been poor

outside of Hull Loss measures

Time

Nu

mb

ers

of

Inci

den

ts

Technology

• Engineering• Equipment• Safety • Compliance

Improvements in Safety PerformanceImprovements in Safety Performance

Lost Workday Incidents per 100 Employees in US

Fre

qu

ency

Rat

e

9

8

7

6

5

4

3

2

1

0DuPont Chem

IndustryAircraft& Parts

Mining ConstructionLogging SteelFoundry

TransbyAir

0.03

1.1

5.3

8.4

Industry Average (2.1)

5.5

3.6

2.9

1.6

Aviation isn’t that safeAviation isn’t that safeUS data — 1997US data — 1997

Courtesy DuPont

It doesn’t get better 2001It doesn’t get better 2001

* U.S. Bureau of Labor Statistics, 2001 Data

4.74.95.25.3

9.7

32.62.31.90.30

24681012

DuPontChemicalsMiningRepair ServicesPulp & Paper

Transportation Equip.Primary Metal IndustriesFood & Kindred Prod.Lumber & Wood ProductsTransportation by Air

IndustryAverage (2.6)

Lost Workday Cases per 100 Employees*

Are Airlines safe?Are Airlines safe?• Hull loss statistics imply that most

airlines are very safe for passengers• Injury statistics suggest that airlines

are quite dangerous for their employees

• Do airlines take safety seriously, or only the avoidance of extreme outcomes?

• If they only go for avoidance, how advanced is their safety culture?

Are Airports safe?Are Airports safe?

• Runway incursions are a major problem

• Analyses of the underlying causes show that a lack of effective safety management is at the basis of incursion incidents

• Baggage handling is another source of injuries

• Most organisations do not even know their injury rates

Safety Management SystemsSafety Management Systems

• ICAO has recently mandated Safety Management Systems (SMS)

• Annex 6 (also 11 and 14)• JAR OPS 1/3.037

• I proposed in 1997 that the combination of SMS and Safety Culture could achieve the target of two orders of magnitude improvement in safety performance

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Systems

• Engineering• Equipment• Safety • Compliance

• Integrating HSE

• Certification• Competence• Risk

Assessment

Improvements in HSE PerformanceImprovements in HSE Performance

HSE Management SystemHSE Management SystemA framework for HSE Management in ShellA framework for HSE Management in Shell

Alcohol& Drugs

PolicyAudit Plans

Road Safety Plan

Safety Drills

Security Policy

HSEPolicy

No Structure Structure

Policy

Process

Task

ContinuousImprovement

Safety (HSE Cases)

Mgt.policy link

Safety Management SystemsSafety Management Systems

• Safety Management Systems are about operating with a systematic approach

• The hazards are identified• The controls are in place• Assurance can be provided with a Safety

Case• SMS in aviation is an ICAO standard

(Annex 6)– ATC 2004– Aerodromes 2005– MRO’s 2008– Airlines 2009

Safety CultureSafety Culture

Here are some extracts from the Investigation Report …

“ The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture….

…Cultural traits and organizational practices detrimental to safety were allowed to develop, including:

• reliance on past success as a substitute for sound engineering

• organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion …”

BP - Texas CityBP - Texas City

• 15 dead, 170 severely injured, >500 wounded• More than $ 700 M set aside for compensation

and $ 1000 M for remediation & improvement• Not including lost production

• BP’s Texas City refinery had a major explosion on March 23rd 2005 of the isomerization plant

BP Analysis of Texas CityBP Analysis of Texas City• Most attention paid to what happened and

how (Investigation)

• But, the report distinguished between (Analysis)– immediate causes (What happened?)– management system causes (Why did it happen?)– cultural issues (How was it allowed to happen?)

• Mogford report set a new standard in Safety Investigation and Analysis

BP’s Own AnalysisBP’s Own AnalysisImmediate causes • Violations by

individuals and supervisors

• Lack of knowledge of hazards present

• Poor decision making• Seen as routine

activities• Defective safety

devices• Inadequate equipment

Cultural issues• Poorly motivated workforce,

behaved in a disempowered way

• Lack of enforcement of following procedures

• Lack of role models at supervisor and superintendent levels

• Little expectation of behaviours and performance

• No consequences of good or bad performance

• Fear to challenge and say “no”• Lack of teamwork evidenced by

many behaviours and attitudes

Similarities between BP and Similarities between BP and Shell studyShell study

In Shell

•I am satisfied with my involvement in decisions that affect my work

•Where I work, we are treated with respect

•My team leader coaches me effectively

•My team leader supports me in balancing my work and my personal life

•I believe what leaders in my organisation say

•I get a clear sense of my organisation's direction from my leadership team

In BP

- Management where I work listens to my ideas for improvement

- My line manager/team leader treats me fairly

- My line manager/team leader would support me if I needed help in handling tensions between my work and personal life

- My pay is linked to my performance

Culture is a basic issue in all these Culture is a basic issue in all these accidentsaccidents

• Our culture determines what we regard as important

• Our culture determines what we see as normal and acceptable

• Culture acts as a multiplier on all safety elements– Plant - equipment– Process – People

Safety CultureSafety CultureThe Added IngredientThe Added Ingredient

• Safety Management Systems and Safety Cases provide a systematic approach to safety

• Safety Management systems are still driven by paper• Minimum standards can be defined but this is not the

best way to obtain the extra benefits• A good safety culture fills in the gaps

• “Sound systems, practices and procedures are not adequate if merely practised mechanically. They require an effective safety culture to flourish.”

• So you need Safety Management Systems AND a Safety Culture

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Systems

Culture

• Engineering• Equipment• Safety • Compliance

• Integrating HSE

• Certification• Competence• Risk

Assessment

• Behaviours• Leadership • Accountability• Attitudes• HSE as a profit centre

Improvements in Safety Improvements in Safety PerformancePerformance

Characteristics of a Safety Characteristics of a Safety CultureCulture

• Informed - Managers know what is really going on and workforce is willing to report their own errors and near misses

• Wary - ready for the unexpected• Just - a ‘no blame’ culture, with a clear

line between the acceptable and unacceptable

• Flexible - operates according to need• Learning - willing to adapt and

implement necessary reforms

PATHOLOGICAL

REACTIVE

CALCULATIVE

PROACTIVE

GENERATIVE

Safety Culture indicators Safety Culture indicators chronic uneasesafety seen as a profit centrenew ideas are welcomed

we are serious, but why don’t they do what they’re told?endless discussions to re-classify accidentsSafety is high on the agenda after an accident

the lawyers said it was OKof course we have accidents, it’s a dangerous businesssack the idiot who had the accident

resources are available to fix things before an accidentmanagement is open but still obsessed with statisticsprocedures are “owned” by the workforce

we cracked it!lots and lots of auditsHSE advisers chasing statistics

The HSSE Culture LadderThe HSSE Culture Ladder

CALCULATIVEWe have systems in place to

manage all hazards

PROACTIVESafety leadership and values

drive continuous improvement

REACTIVESafety is important, we do a lotevery time we have an accident

PATHOLOGICALWho cares as long as

we're not caught

Incr

easi

ngly

Info

rmed

Incr

easi

ng T

rust

and

Acc

ount

abili

ty

GENERATIVE (HRO)HSE is how we do business

round here

Safety CultureSafety Culture“A good safety culture is the embodiment of effective

programs, decision making and accountability at all levels.

When we talk about safety culture, we are talking first and foremost about how managerial decisions are made, about the incentives and disincentives within an organization for promoting safety.

One thing I have often observed is that there is a great gap between what executives believe to be the safety culture of an organization and what it actually is on the ground. Almost every executive believes he or she is conveying a message that safety is number one. But it is not always so in reality.”

• Carolyn W. Merritt - U.S. Chemical Safety and Hazard Investigation Board November 2005

So what does a So what does a Generative cultureGenerative culture

look like?look like?

The High Reliability The High Reliability Organisation (HRO)Organisation (HRO)

• World Champions 1904 ?• How do they do it? - 2007?

The Generative OrganizationThe Generative Organization• Low profile - always to be relied on• Low accident rate - but there is always bad luck• Active involvement and accountability for all• Workforce initiative in safety and operations• Short and effective feedback lines• Procedures under constant scrutiny• Training, cross-training and more training• Benchmarking against others, inside and out• Obsessive planning - many scenarios create requisite variety• Willing to try new ideas, but accept the risk of failures• Chronic Unease

• Can be equated with the High Reliability Organisation (HRO)

Safety cultures allow taking risksSafety cultures allow taking risksTaking risks makes moneyTaking risks makes money

• Safety management can only manage standard hazards

• Safety cultures take more account of the hazards and ways of living safely

• This enables them to operate closer to the edge

• Return on capital is a function of risks taken

• Safety cultures are not reckless• This is the advantage

The EdgeThe Edge

Inherently Safe

Normally Safe

Normally Safe

The Edge

The Edge

12%9%

6%Return onReturn onCapitalCapitalInvestedInvested

No need

Safety Management Systems

Safety Culture

How to create a Safety CultureHow to create a Safety Culture

• Depends on where you are starting from - you don’t get to the end in one step, unfortunately, all the steps have to be traversed

• Becoming a Safety Culture involves acquiring and then maintaining a set of skills

• The two major factors are informedness and trust, so these have to be developed

• Be systematic (Safety Management Systems are a start) and then learn to operate with the unknown as well

Creating a Safety Culture IICreating a Safety Culture II

• Have the program run right from the top - It’s the CEO’s pet project

• Appoint a senior champion who is dedicated and willing to stick it out, even when it gets hard

• The champion reports direct to the CEO and the board

• Recognise that it will be uncomfortable, safety cultures are different, not just an add-on

Which drivers for which culture?Which drivers for which culture?• Pathological respond to regulation

– They don’t know the rest or it won’t happen anyway– They may be shifted if they are confronted with the costs

• Reactive respond to ethics, laws, regulation and accident costs (everything!)

• Calculative respond to regulation– They may be ethical but regulations and systems are they

way they succeed

• Proactive respond to costs (as lost benefits)– Regulations are seen as defining minimum requirements

• Generative respond to benefits and self-image– They see it as strange if you don’t have HSE as a priority

Developing a Safety Culture:Developing a Safety Culture:Informed and LearningInformed and Learning

• Agree on ways to analyse incidents to reveal individual and system issues

• Develop reporting systems that are easy to use (compact, open-ended, impersonal)

• Encourage the workforce (air and ground) to realise that all incidents are worth reporting

• Experiment with changes when new information comes in, don’t be afraid to admit failure first time round

• Practice management in wanting to know from near misses before they become accidents

Developing a Safety Culture:Developing a Safety Culture:JustJust

• Get rid of the idea that blame is a useful concept (this is hard to do)

• Define clear lines between the acceptable and the unacceptable

• Have those involved draw up the guidelines, do not impose from above if you want them to be accepted

• Have clear procedures about what to do with other forms of non-compliance

Developing a Safety Culture:Developing a Safety Culture:WaryWary

• Most dangerous situations can be planned for• Planning is never a bad thing, but• Your remaining problems arise from what you

never thought of or considered, so:– Construct systems that can cope with the

unexpected– Practice Chronic Unease

• Chronic Unease means moving from– “We haven’t had an accident, aren’t we doing

well” to– “We haven’t had an accident, what are we

overlooking? life isn’t that fair”

Developing a Safety Culture:Developing a Safety Culture:FlexibleFlexible

• Develop a workforce that is more than ‘just’ competent - multi-skilling is easier or even necessary in smaller airlines

• Move control down as far as possible • Develop the possibilities for ‘variance

procedures’ where operations are defined by what is safe and sensible– Risk assessment of ongoing activities– Competence defined limits on freedom to act– Lots of communication when there are

differences

Maintaining a Safety CultureMaintaining a Safety Culture

• The greatest enemy is success - complacency is easy– If you find yourself saying “Now we can get back

to the real business” you have lost it• Keep maintenance as a target in its own right• Keep close to the hazards

– The most effective way to stay awake is to stay scared

– If you can’t find your own accidents, go find someone else’s

• Never let up

Safety CultureSafety CultureThe values of an OrganisationThe values of an Organisation

• Safety culture determines performance as well as safety

• The culture is expressed by all parts of the organisation– Flight deck– Cabin crew– Maintenance – Ground staff

• The cabin staff and check-in personnel provide the main indication of the culture to the paying public

• The Australian Defence Force has explicitly stated that it wants to become Generative

Challenges to Safety CultureChallenges to Safety Culture

• The overall culture itself is a source of problems

• Regulators can create legal barriers if their own culture is less advanced

• Management can lose their nerve and promote the champions away

• Change is hard and the status quo comfortable

Why Don’t They?Why Don’t They?• Organisational cultures are only capable of

understanding the world in ways appropriate to their current safety culture level and their readiness to change– Less advanced cultures just don’t

understand that it’s better up there!• Counter-pressures exist to force

organisations back towards the Calculative• The Generative represents a vast leap into

the unknown

ConclusionConclusion• Safe organisations make money where

others do not dare to operate• Safety cultures have increased trust (and

lower costs)– From management to workforce– From workforce to management

• Airlines, airports and Air Traffic Control can implement Safety Management Systems and then develop generative organisations