Safety Culture
What it is and
the Six steps Necessary to Achieve it
Presented at
Flight Safety Foundation
Business Aviation Safety Summit
Montreal, PQ April 11, 2013
Presented by
Gordon Dupont
Safety Culture
Is a lot more than a sign
Safety First
Unless it costs money
Unless it costs money
Unless it costs money
it costs money
What is Safety?
• The state of being Safe
• The condition of being Safe
from undergoing or causing
hurt, injury or loss
Webster’s Dictionary
• The risk (odds) of something causing you grief is
As Low As Reasonably Practical (ALARP)
G. Dupont
What is a Safety Culture?
It is a Culture where:
Safety is treated seriously by the management and all
employees
Safety goals are set and all work toward their
achievement
all company employees are trained and encouraged to
think and work Safely at all times
a system is in place to report Safety concerns
all believe that Safety does not have to come at the cost
of productivity or profit
Safety is an integral part of the way the company
operates
The company has a framework to accomplish all of the
above –A Safety Management System (SMS)
Gordon Dupont
Why is a Safety Culture so
important now?
The probability (risk) of being killed in an aircraft
accident varies from
1 in 260,000 (Africa)
To
1 in 11,000,000 (45 million 2012 USA)
A difference of 42 times better
Why?
A Safety Culture makes a difference
50
Major Fatal Airline Accidents per year
Airline Aircraft in service
45
25,598
40
35
12,595
30
25
1997
2016
20
We must
continue to
do better
Hull loss
accidents
per year
15
10
Millions of departures
5
0
Hull loss accident rate
1965
1975
1985
1995
Year
2005
2015
Boeing Aircraft Corporation
By 2016 there will be one major fatal accident
per week somewhere in the world
What does a Safety Culture look like?
You’ll Know it
When You Work in it
• It is very difficult to measure accurately
• It is seen by the way things are done around
the organization
• It is heavily influenced by management
• It is constantly changing
A Safety Culture must have
the 3 “C’s”
C ommitment
Management’s True motivation and allocation of resources
C ompetence
Knowledge to know how to achieve the
organization’s Safety goals
C ognizance
Awareness that it is a never
ending battle
Mintzberg
The Six Steps to a
Safety Culture
1.
JUST culture
James Reason
Gordon Dupont
Step 1
A Just Culture
• A Just Culture is the foundation of
any Safety Culture
• Where “Honest & At-Risk”
mistakes do not result in discipline
• Where an Administrative policy
spells out “Reckless Behaviour”
• Where persons can admit to an
error without fear of punishment
Screw up and
you’re history
But what about Discipline?
• What is the real purpose of
discipline?
• REVENGE?
Holding the Person Accountable
TO BE SEEN TO BE DOING
SOMETHING?
TRADITION?
To ensure an occurrence
does not happen again
If only they all wore hats
Degree of Discipline
X Was the act deliberate with a reasonable

knowledge of the possible consequences?
X Has the person made similar errors in the past?

X Do they accept responsibility for their actions?

Degree of Discipline
X Was the act deliberate with a reasonable

knowledge of the possible consequences?
X Has the person made similar errors in the past?

X Do they accept responsibility for their actions?

X Has the person learned from the experience?

X Are they likely to do it again?

Anyone can make a
mistake
but
only a fool
(company or individual)
makes the
same mistake twice
Degree of Discipline
X Was the act deliberate with a reasonable

knowledge of the possible consequences?
X Has the person made similar errors in the past?

X Do they accept responsibility for their actions?

X Has the person learned from the experience?

X Are they likely to do it again?

Remember the reason for Discipline
To Ensure It Does Not Happen Again
Discipline – To Ensure That It Does Not Happen Again
He was found
NOT GUILTY
• No hull insurance
• Wife severely injured
• Pilot severely injured
• Off work for a month
SAFETY culture
2.
1.
TRUSTING culture
JUST culture
(G. Dupont)
James Reason
Gordon Dupont
Step 2
A Trusting Culture
Levels of Trust
Synergistic - WE can
solve the problem
High
(Win Win)
Respectful - Compromise
(Win Lose – Lose Win)
Trust
Low
Defensive – Us vs. Them (Lose Lose)
Cooperation
High
SAFETY culture
3.
2.
1.
REPORTING culture
TRUSTING culture
JUST culture
(G. Dupont)
James Reason
Gordon Dupont
Step 3
A Reporting Culture
provides the means to capture the
lessons to be learned arising from
human errors, near misses
or free lessons
You can’t fix what you don’t know
MEDA (Maintenance Error Decision Aid) Objectives
• Many Current Error Investigation Processes
Event
Occurs
Investigation
Reveals Event
Caused by
Maintenance
Error
Determine
Who Made
Error
Administer
Discipline
• The MEDA Process
Event
Occurs
Investigation
Reveals Event
Caused by
Maintenance
Error
Add to
Maintenance
Error Data
Base
Determine
Who Made
Error
•Interview Responsible
Personnel
• Find Contributing
Factors
• Get Ideas for Process
Improvement
Make Process Improvements
Based on Contributing Factors
•Based on This Event
•Based on Analysis of Data
for Multiple Events
Follow-up to
Obtain
Additional
Contributing
Factors and
Information
Provide Feedback
to All Employees
Affected by
Process
Improvements
Don’t Sweat the Small Stuff
And You Will Avoid Having to
Sweat the Big Stuff
Gordon Dupont
This is what SMS is all about
The Small Stuff has the potential
to become the Big Stuff
For Example
SAFETY culture
4.
3.
2.
1.
LEARNING culture
REPORTING culture
TRUSTING culture
JUST culture
(G. Dupont)
James Reason
Gordon Dupont
Step 4.
A Learning Culture
Enables us to take the reports with their “Free lessons”
and through Risk Management lower the hazards that
threaten the Safety of the organization
Enables us to analyze what we weren’t even aware of
before
We are able to fix the problem (Hazard) before it
causes an accident
Takes us from the Reactive level to the Proactive level
Step 4
A Learning Culture
• Where human factors training is
provided to all on an ongoing basis
• Where incident data is kept and analyzed to
find trends and develop Safety nets
• Where major changes are carried out when
the present system is not sufficiently Safe
• Where feedback is provided as a means of
learning from all incidents
SAFETY culture
5.
4.
3.
2.
1.
INFORMED culture
LEARNING culture
REPORTING culture
TRUSTING culture
JUST culture
(G. Dupont)
James Reason
Gordon Dupont
Step 5
An Informed Culture
Where everyone knows
the organization’s true
Safety commitment
1. A Mission Statement - Posted
A Mission Statement
That Everyone Knows
Step 5
An Informed Culture
Where everyone knows
the organization’s true
Safety commitment
1. A Mission Statement - Posted
2. A Safety Policy - Posted
Management
Managers and supervisors
Managers and supervisors
Supervisors
Supervisory
Employee
Employee
Everyone
This is an excellent one
Step 5
An Informed Culture
Where everyone knows
the organization’s true
Safety commitment
1.A Mission Statement - Posted
2.A Safety Policy - Posted
3. An Administrative Policy – Known by all
4. Long term Safety goals – Known by all who
work toward them
5. Optional - Core Values Statement - Posted
SAFETY culture
6.
5.
4.
3.
2.
1.
FLEXIBLE culture
INFORMED culture
LEARNING culture
REPORTING culture
TRUSTING culture
JUST culture
(G. Dupont)
James Reason
Gordon Dupont
Step 6
A Flexible Culture
• Where necessary changes are
made in order to improve Safety
• Where the organization is
constantly looking for better ways to work Safer
• Where the status quo is not considered an option in
the quest to lower errors
• Where there is a “Chronic Unease” that in spite of
all efforts, human error will still occur
• Where an Emergency Response Plan (ERP) is in
place in the event of an error occurring
SAFETY culture
6.
5.
4.
3.
2.
1.
FLEXIBLE culture
INFORMED culture
LEARNING culture
REPORTING culture
TRUSTING culture
JUST culture
(G. Dupont)
James Reason
Gordon Dupont
Thank You
for the Opportunity to Provide this Message
Gordon Dupont
What Class of Error?
Honest,
At-Risk,
Reckless
How do we measure this?