building a just culture for safety performance - can it ... · just culture – why? a proactive...
TRANSCRIPT
Building a Just Culture for Safety
Performance
- Can it work across national cultures?
Keven Baines – Director
25th March 2015
CHC Safety & Quality Summit
© 2015 Baines Simmons Limited
Workshop flow
2
3. How to build one?
4. Does it deliver/work across national cultures?
2. What is it?
1. Just Culture – why?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture – why?
A proactive safety culture that is founded upon a Just Culture
Being Just is the bedrock of safety performance
Encourages openness and proactive reporting of hazards
Enables you to discover what people have to do to get the job
done
Facilitates risk-based decision-making
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How did Just Culture evolve?
Blame and Train
Culture
No Blame Culture
Just Culture
Just Culture for safety performance 4
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Just Culture the key Safety Performance enabler
A Proactive Culture is the
bedrock of safety performance.
A Proactive Safety Culture
encompasses an organisation’s
commonly held perceptions and
beliefs regarding safety and has the
potential to significantly influence
people’s behaviour.
A Proactive Safety Culture is
founded upon a Just Culture in
which individuals freely and openly
share safety-related information in
an atmosphere of trust, born from
a sense of justice.
Just Culture for safety performance
© 2015 Baines Simmons Limited
What are the benefits of Just Culture?
Information
Risks
Improved (risk-based) decision-making
Just Culture
Reporting
Confidence in being treated fairly and feeling
able to change something
Just Culture for safety performance
© 2015 Baines Simmons Limited
Regulatory context
New European regulation on mandatory occurrence
reporting
(No.376/2104) in force from November 2015
“Each organisation established in a Member State shall
.. adopt internal rules describing how ‘just culture’ principles ... are
guaranteed and implemented within that organisation.”
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Definition of Just Culture
A culture that recognises that competent
professionals make errors and acknowledges
that even competent professionals will develop
unhealthy norms (shortcuts, routine rule
violations), but has zero tolerance for reckless
behaviour
Just Culture for safety performance
© 2015 Baines Simmons Limited
0%
100%
Human
Reliability
Performance Influencing Factors (PIFs)
The Human Reliability Curve
Human
Error
Normal
Operation
The ‘Error Zone’
It’s part of the human condition to err
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Types of error
Because I didn’t quite do what I wanted to do: error (slip)
Because I forgot or wasn’t concentrating: error (lapse)
Because I made the ‘wrong’ decision or plan: mistake
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Why are rules intentionally broken?
Because there is no other choice to get the job done:
situational violation
Because this situation has never been imagined: exceptional
violation
Because it’s what we do here: violation for organisational gain
Cant, don't, won’t
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Error or violation?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Error or violation?
39 times...
Just Culture for safety performance
© 2015 Baines Simmons Limited
Error or violation?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Do YOU role model it?
Can YOU find it? Can YOU explain it?
Do YOU follow the
process?
“Thanks, but we already have a Just Culture”
Just
Culture
Defined
Understood
Applied Demonstrated
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture Self assessment
16
Client’s average score 43%
Just Culture for safety performance
© 2015 Baines Simmons Limited
It can be measured?
17
Just Culture for safety performance
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Company 1 - safety culture diagnostic
Just Culture for safety performance
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Company 2 - safety culture diagnostic
Just Culture for safety performance
© 2015 Baines Simmons Limited
The safety performance indicators for Just culture
Just Culture for safety performance
© 2015 Baines Simmons Limited
Workshop flow
21
3. How to build one?
4. Does it deliver/work across national cultures?
2. What is it?
1. Just Culture – why?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture – How?
Understand Build Power-up Perform
Just culture assessment
Safety culture diagnostic
Where are we
now?
What do
we need
to put in
place?
Safety vision
Policies
Procedures
Investigation process
Just Culture toolkit
How do
we
energise
our
staff?
Competence devt
Coaching
Promotion
Education
How do we
sustain our
culture? How
do we know it
is working?
Assurance
Metrics
Balanced scorecard
Safety culture diagnostic...
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture Vision
By the end of 2016 we will have:
...opened up the culture through a high degree of trust between staff and all levels of
management
...everyone able to describe our Just Culture and it will positively shape their decision
making
...become increasingly (20% year on year) less occurrence and more hazard centric
...become increasingly 3rd age so that we know what our people have to do to get the
job done
...a culture were unjustified risk taking behaviour will not be tolerated at any level
...everyone with a genuine ability to say “stop” and be supported by us
...with no exception (irrespective of outcome severity) our Just Culture process will
always be applied.
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© 2015 Baines Simmons Limited
Error Management System
Threats
and or CFs
Reactive
Unsafe Act (Error/Mistake/Violation)
Event (Unwanted Harm)
Occurrence Reporting
Feedback & Promotion to Develop a
Learning Safety Culture
Hazard/Near-Miss/Error/Mistake/Violation Reporting
Pro Active
Data Exploitation to make human-in-the-
system risk based decisions
Interventions
Investigations
Just Culture toolkit - inc. Event Review Group
and or PIFs
Hazards
Just Culture for safety performance
© 2015 Baines Simmons Limited
FAiR® - what is it..?
a ‘behaviour-based system for creating and sustaining a Just Culture’
… to enable an organisation to ensure that interventions consider the
‘Human In The System’ (HITS)
...treating all in a fair and importantly - a consistent manner
Identify effective interventions
Ensure personal accountability is balanced with the desire for learning and
improvement
Focus on actions and intentions rather than consequences
Cross cultural commonality
Just Culture for safety performance
© 2015 Baines Simmons Limited
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© 2015 Baines Simmons Limited
Event Review Group responsibilities
27
To ensure a Human Factors-centric investigation and report is complete
identifying the root cause
contributing factors
Ensuring all the ‘Why did it happen?’ questions have been answered
To ensure effective interventions are put in place following an event
To determine any potential accountability.
Just Culture for safety performance
© 2015 Baines Simmons Limited
Typical Event Review Group composition
SMS Manager
Trained ERG members (an uneven number if possible)
Subject Matter Experts (as required)
To minimise bias and preserve impartiality the Manager of the
area in which the event has occurred should not be part of
the ERG or take part in the related ERG decision(s).
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© 2015 Baines Simmons Limited
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© 2015 Baines Simmons Limited
Workshop flow
31
3. How to build one?
4. Does it deliver/work across national cultures?
2. What is it?
1. Just Culture – why?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture - does it really deliver?
“We are now undertaking activity that would normally only have resulted from an accident,
but in this case, no-one was hurt and nothing was damaged. The last three weeks have seen
some of the most valuable people-centred safety management activity we have conducted.”
Commanding Officer, RAF Lossimouth
“ We are learning things about ourselves that we normally only learn after a funeral and the
loss of jet”
Senior Engineering Manager, military aviation
“I'm stunned by what’s been culturally acceptable and what I'm learning. We are now
motivated to do and learn more.”
Director of Operations, major International Airline
“I’m shocked and I’m depressed, but at least I know where we are now...plotting the course to
point B has been made easier”
Senior Manager, major aircraft manufacturer
Just Culture for safety performance
© 2015 Baines Simmons Limited
Safety culture maturity KPIs
RAF Air Safety Centre
example...
Just Culture for safety performance
© 2015 Baines Simmons Limited
Does it really deliver?
“Labels transposed, been happening for
years we thought everyone knew it?”
Just Culture for safety performance
© 2015 Baines Simmons Limited
Transitioning to safety performance
Just Culture for safety performance
© 2015 Baines Simmons Limited
Transitioning to safety performance
Just Culture for safety performance
© 2015 Baines Simmons Limited
Predictive?
© Baines Simmons Limited 2009 Just Culture for safety performance
© 2015 Baines Simmons Limited
Poor maintenance
practices, 3, 2%
Poor
troubleshooting
standards, 1, 1%
Servicing error, 22,
12%
Poor inspection
standards, 25, 12%
Misinterpritation of
approved data, 5,
3%
Installation error,
100, 52%
Approved data not
followed, 28, 14%
Damage , 2, 1%
Tools left on
aircraft, 1, 1%
Unrecorded work,
2, 1%
Work not certified
before operation of
aircraft, 1, 1%
Error type
Just Culture for safety performance
© 2015 Baines Simmons Limited
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11
24
29
39
66
67
71
72
79
100
140
0 20 40 60 80 100 120 140
N/A
Other
Job / Task
Equipment / Tools / Parts
Environment / Facilities
Communication Issues
Technical Knowledge/Skills
Leadership / Supervision
Organizational Factors
Aircraft Design/Configuration/Parts
Factors Affecting Individual Performance
Information
Summary of Contributing Factors
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
2
2
2
8
9
13
15
17
26
37
0 5 10 15 20 25 30 35 40
Inappropriate for the task
Misinterpretation
N/A
(blank)
Too much / conflicting Information
Not Understandable
Unavailable / inaccessible
Incorrect
Other
Information not used
Information
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
4
4
4
5
6
12
18
19
24
0 5 10 15 20 25
N/A
Peer pressure
(blank)
Other
Memory lapse
Fatigue
Complacency
Workplace distractions / interruptions
Time constraints
Factors Affecting Individual Performance
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
1
2
2
3
5
5
8
10
15
25
0 5 10 15 20 25
Work process/procedure
Complex
Incorrect
N/A
Not User Friendly
(blank)
Inaccessible
Aircraft configuration variability
Other
Easy to install incorrectly
Aircraft Design / Configuration / Parts
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
2
3
3
4
4
4
7
10
13
19
0 2 4 6 8 10 12 14 16 18 20
N/A
Time contraints
Workplace distractions/interuptions
Company policies
Corporate change/ restructuring
Other
Work process / procedure not documented
Company work processes
Quality of support from technical organisations
Work process / procedure not followed
Organizational Factors
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
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1
2
3
4
5
10
10
16
18
0 2 4 6 8 10 12 14 16 18
Inadequate prio rit isat io n o f wo rk
Wo rk pro cess/ pro cedure
N o t eno ugh staff
Unrealist ic att itude / expectat io ns
N / A
Inadequate delegat io n / assignment o f task
Other
(blank)
Inadequate planning / o rganisat io n o f tasks
A mo unt o f supervisio n
Leadership / Supervision
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
2
2
2
3
3
4
5
6
6
29
0 5 10 15 20 25 30
N/A
Planning/orgainization of tasks
Work process/procedure
Inadequate skills
Skills
Inadequate Airline Process Knowledge
Inadequate task planning
Inadequate Aircraft System Knowledge
Other
Inadequate task knowledge
Technical Knowledge / Skills
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
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1
1
3
4
9
10
11
12
12
0 2 4 6 8 10 12
Inadequate task kno wledge
Quality o f suppo rt fro m technical o rganisat io ns
Wo rk pro cess/ pro cedure no t do cumented
N / A
B etween Lead and M anagement
B etween maintenance crew and lead
B etween departments
B etween shif ts
B etween engineering staff
Other
Communication Issues
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
1
2
2
3
4
4
4
5
5
6
0 1 2 3 4 5 6
Workplace distractions/interuptions
Cleanliness
Rain
(blank)
Hot
N/A
Other
Cold
Lighting
High noise levels
Environment / Facilities
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
1
1
1
1
2
2
4
4
5
6
0 1 2 3 4 5 6
Not understandable
Not Used
Unreliable
Work group normal practice (norm)
Information not used
Unsafe
Inappropriate for the task
N/A
Unavailable / inaccessible
Other
Equipment / Tools / Parts
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
2
3
3
3
4
4
6
7
10
10
0 1 2 3 4 5 6 7 8 9 10
Work process/procedure
Complex / confusing
Work process/procedure not followed
(blank)
Complacency
N/A
Different from other similar tasks
Other
New task or task change
Repetitive / monotonous
Job / Task
Installation error
Just Culture for safety performance
© 2015 Baines Simmons Limited
6
11
24
29
39
66
67
71
72
79
100
140
0 20 40 60 80 100 120 140
N/A
Other
Job / Task
Equipment / Tools / Parts
Environment / Facilities
Communication Issues
Technical Knowledge/Skills
Leadership / Supervision
Organizational Factors
Aircraft Design/Configuration/Parts
Factors Affecting Individual Performance
Information
Summary of Contributing Factors
Just Culture for safety performance
© 2015 Baines Simmons Limited
Lastly, please remember…
FAiR has been designed to offer a ‘handrail’ to aid
organisations
Meant to assist organisations practical apply sound Human
Factors theory, especially in the area of matching behaviours
to interventions
It is absolutely dependent on:
a structured process
‘leadership’ buy-in
and the competence of individuals using it.
Just Culture for safety performance
© 2015 Baines Simmons Limited
Conclusion
A proactive safety culture that is founded upon a Just Culture
Being Just is the bedrock of safety performance
Encourages openness and proactive reporting of hazards
Enables you to discover what people have to do to get the job
done
Facilitates Risk Based Decision Making
If commonly applied will be successful across international
businesses.
52 Just Culture for safety performance
© 2015 Baines Simmons Limited
Date for your diary
53 Just Culture for safety performance