Achieving a Safety Culture in
Aviation
Patrick Hudson
Leiden University
Contents
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Safety Management in aviation
Safety Culture - the added extra
The Evolution of Culture
Acquiring and maintaining a Safety Culture
Conclusions
Aviation 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
Improvements in Safety Performance
Numbers of Incidents
Technology
•
•
•
•
Engineering
Equipment
Safety
Compliance
Time
Aviation isn’t that safe
US data — 1997
Lost Workday Incidents per 100 Employees in US
9
8.4
Frequency Rate
8
7
6
5.3
5.5
5
3.6
4
3
Industry Average (2.1)
2
1.1
1
0
2.9
1.6
0.03
DuPont
Chem
Industry
Courtesy DuPont
Aircraft
& Parts
Mining ConstructionLogging
Steel
Foundry
Trans
by
Air
It doesn’t get better 2001
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?
• 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 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
Improvements in HSE Performance
Numbers of Incidents
Technology
Systems
•
•
•
•
Engineering
Equipment
Safety
Compliance
•
•
•
•
Time
Integrating HSE
Certification
Competence
Risk Assessment
HSE Management System
A framework for HSE Management in Shell
Security
Policy
Road
Safety
Plan
Alcohol
& Drugs
Policy
HSE
Policy
Audit
Plans
Safety
Drills
Policy
Continuous
Improvement
Mgt.
policy
link
Process
Safety (HSE Cases)
Task
No Structure
Structure
Safety 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)
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ATC 2004
Aerodromes 2005
MRO’s 2008
Airlines 2009
Safety 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 City
• BP’s Texas City
refinery had a
major explosion
on March 23rd
2005 of the
isomerization
• plant
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 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 Analysis
Immediate 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
Shell study
In BP
In Shell
- Management where I work listens to my
•I am satisfied with my involvement in
decisions that affect my work
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
•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
Culture is a basic issue in all these
accidents
• 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 Culture
The 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
Improvements in Safety Performance
Numbers of Incidents
Technology
Systems
•
•
•
•
Engineering
Equipment
Safety
Compliance
•
•
•
•
Time
Integrating HSE
Certification
Competence
Risk Assessment
•
•
•
•
•
Behaviours
Leadership
Accountability
Attitudes
HSE as a profit centre
Culture
Characteristics of a Safety
Culture
• 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
Safety Culture indicators
GENERATIVE
chronic unease
safety seen as a profit centre
new ideas are welcomed
PROACTIVE
resources are available to fix things before an accident
management is open but still obsessed with statistics
procedures are “owned” by the workforce
CALCULATIVE
REACTIVE
PATHOLOGICAL
we cracked it!
lots and lots of audits
HSE advisers chasing statistics
we are serious, but why don’t they do what they’re told?
endless discussions to re-classify accidents
Safety is high on the agenda after an accident
the lawyers said it was OK
of course we have accidents, it’s a dangerous business
sack the idiot who had the accident
The HSSE Culture Ladder
GENERATIVE (HRO)
HSE is how we do business
round here
PROACTIVE
Safety leadership and values
drive continuous improvement
CALCULATIVE
We have systems in place to
manage all hazards
REACTIVE
Safety is important, we do a lot
every time we have an accident
PATHOLOGICAL
Who cares as long as
we're not caught
Safety 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
Generative culture
look like?
The High Reliability
Organisation (HRO)
• World Champions 1904 ?
• How do they do it? - 2007?
The Generative Organization
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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 risks
Taking 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 Edge
The Edge
Normally Safe
Inherently
Safe
6%
No need
9%
Normally Safe
Safety Management Systems
Safety Culture
The Edge
12%
Return on
Capital
Invested
How 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 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 addon
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:
Informed 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:
Just
• 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:
Wary
• 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:
Flexible
• 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 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 Culture
The values of an Organisation
• Safety culture determines performance as well as safety
• The culture is expressed by all parts of the organisation
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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 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?
• 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
Conclusion
• 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