DEFENCE AVIATION ERROR MANAGEMENT SYSTEM (DAEMS) PROJECT
COMMUNCATIONS LINES
These ‘lines’, ‘sound bites’ and ‘bullets’ are intended for use in spreading awareness and
understanding of error management and the DAEMS project through MAA, ODH and DDH
communications plans.
ERROR MANAGEMENT AND JUST CULTURE
WHY ?
There is increased scrutiny on Defence, particularly with regard to safety and airworthiness,
following the publication of the Nimrod Review Report in 2009.
Everyone has a part to play in ensuring that we carry out our business safely, but individuals
appointed as Duty Holders are personally accountable for Air Safety and safe operations within their
areas of responsibility. They need full sight of Air Safety risks and issues in order to be able to take
timely and appropriate action – and they need us to help by reporting potential problems, nearmisses and safety-related errors when we see them.
Defence Aviation already has a longstanding occurrence reporting system, now centrally hosted on
ASIMS, which is very effective at gathering reports on ‘things that went wrong’. However, it is less
effective at gathering information on near-misses and errors that do not result in a reportable
incident. As a result, action taken based on analysis of ASIMS reports is largely reactive. We need
to be able to identify where things could go wrong as well as where things have gone wrong so that
action can be taken much earlier in the potential accident chain. We need to be able to use a
reporting system that will allow us to report potential issues as well as actual occurrences.
WHAT ?
One of the recommendations of the Nimrod Review Report was that the MOD should build on the
success of the RAF’s work on Error Management Systems in the maintenance environment, and
introduce a pan-Defence Aviation Error Management System in support of Air Safety.
Error management systems provide a way to report and manage those ‘potential issues’ that ‘could’
have become a link in an accident chain. Successful error management systems enable
businesses operating in complex, high-risk sectors such as aviation to maximise their ability to
identify, mitigate and manage risks.
They do this by involving all of their people in the reporting and subsequent analysis of potential
hazards, system failures and human errors, in order to prevent recurrences. Using error
management effectively will enable us, across Defence Aviation, to improve our Air Safety reporting
and management.
Open and honest reporting of hazards, near misses and mishaps allows us to learn from our
mistakes, both individually and corporately. This is an important part of our broader Air Safety
education programme, and key to preventing avoidable accidents. Equally importantly, in this era of
squeezed Defence budgets, it can also help us to secure funding to improve equipment and training
by producing compelling evidence wherever there is a serious safety requirement.
At the heart of error management is the idea that error is a normal part of any human activity,
whether flying, maintaining, controlling or any other aviation related task. An error has occurred
when an aircraft or system with human interaction fails to perform in the manner expected. This
could be because of system failings (for example, manning shortages, equipment availability, or
ambiguous publications), as well as the errors made by individuals.
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Consequently error management involves all of us: aircrew, engineers and technicians, airspace
and air traffic controllers, movements and ground handling personnel and others (including their
supervisors) – in fact any person either directly or indirectly involved with aviation. You’ll hear these
groups talked about as the ‘4 worlds’ of Defence aviation – but in essence this means you.
HOW ?
The Defence Aviation Error Management System – DAEMS for short – project is an MOD-wide
initiative to promote better air safety and operating efficiency by more effective reporting, better
investigation and better lessons learned.
DAEMS is not an IT system, but a combination of policies, processes and tools for reporting and
analysing errors and near misses in Defence aviation. It uses the existing ASIMS computer-based
reporting system, database and analysis tool, and includes the training that you will need to
understand how you can play your part. This training is intended to show why error management is
such an important part of our safety management systems, and to explain the role that we all have
in making it work.
The implementation of ‘4 worlds’ error management at Defence Aviation HQs and units is a key
objective in the Air Safety Management Plans of all of the 3 Services and the 5 Operational Duty
Holders,1 each of which sets a target date for these to be in place.2
The implementation programme for error management through the DAEMS project is being
supported by a technical support contract that will provide training and support for implementation at
HQ and unit level through a single contractor – Baines Simmons Ltd, who also supported earlier
work on error management in the Army and RAF.
Training has begun at HQ level so that staff officers, and those others within Command HQs who
support them, can understand the benefits of error management systems and how to make use of
the results that these will produce at unit level. This is being followed by a programme of training
and implementation at units, coordinated by MAA, led by single Service Flight Safety staff, and
supported by Baines Simmons.
Each unit’s involvement begins with an assessment visit, followed by 2 to 3 weeks of planning and
preparation, leading to a tailored programme of on-site training. This consists of a number of
courses in human factors and error management designed to meet the needs of all unit personnel at
junior, middle and senior management level, and for those who have specialist roles to plays as
occurrence investigators, error management coordinators, or members of review groups.
At the end of this programme the unit will be able to start operating its error management system,
and to make use of the reports that people submit. Baines Simmons specialists will remain
available to the unit for some time afterwards to resolve any ‘teething problems’, and will continue to
provide on-call support and advice, through Flight Safety staff, to ensure that error management can
be exploited effectively, and honest and open reporting encouraged, as best as possible.
Of course, the system will only be as good as the information put into it and people’s willingness to
report is fundamental to the success of this initiative. Commanders at all levels must encourage
open and honest reporting by applying a Just Culture, supported by their assurance that when
things go wrong personnel will be treated fairly and consistently, and will only be disciplined where it
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2
The 5 Operational Duty Holders are COS (A&C) in HQ Navy Cmd, Comd JHC, and the AOCs of Nos 1, 2 and 22 (Training) Groups.
Objective and targets for each of the 5 Air Safety Management Plans (ASMP) are:
Navy Cmd ASMS (BRd 765 Vol 1) Chap 2 Objective 0202d – foster an assured safety culture through positive leadership
supported by safety reporting mechanisms; target of increased reporting of hazards with the introduction of DAEMS.
JHC ASMP Objective 4 – Open Reporting Culture, with target for full embodiment of DAEMS across JHC by Oct 13.
1 Gp ASMP Objective 4 – establishment of an Open Reporting Culture, with target for compliance with DAEMS across 1 Gp by
Apr 12.
2 Gp ASMP Enabler B – Positive Reporting Culture, with targets for implementation of a 4-worlds EMS across 2 Gp by Apr 12
and full embodiment of DAEMS by Apr 14.
22 (Trg) Gp ASMP – Objective 3 – Reporting Culture, with targets for implementation of a 4-worlds EMS by Apr 12 and
DAEMS across 22 (Trg) Gp by Apr 14.
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is clear that they had malicious intent or erred because of selfish self-interest. While there may
always be consequences for those who ‘cross the line’ from an honest mistake into culpable
negligence, it is important that we all understand where these lines lie, how they are drawn and
what mechanisms are in place to protect them when they admit to an error. Anybody who makes or
identifies honest errors can feel able to report them without unwarranted fear of harm to their career
or personal standing.
Effective error management, based on open and honest reporting, has an important part to play in
the management and improvement of Air Safety. Make the most of the training opportunity that the
DAEMS project will provide, and make sure that you understand the part that you can play in error
management to support Air Safety. Most importantly, if you do see something that you think is not
right – or, indeed, make an honest error – then report it. With your help, we can use error
management in a Just Culture to make military air operations safer still.
JUST CULTURE
A Just Culture is an open and honest reporting culture in which all personnel, regardless of status,
experience or employer can expect to be treated in a fair, consistent, objective and timely manner.
In order to ensure the highest possible Air Safety standards we must actively manage events and
balance the potentially conflicting requirements of safety and standards with operational necessity. I
intend to do this within a Just Culture that encourages open and honest reporting of such events. It
is the human condition to make errors, and human factors play an important role in aviation and
safety. However, humans can also recognises best practice that meets the highest regulatory
standards, and can contribute actively to improving safety. People will be commended for owning
up to mistakes made in an honest endeavour to do their best.
Defence aviation will follow a defined, consistent system for the management of errors. The
deciding part of this system will be independent of the employer or chain of command. This is
neither a “blame” nor “no-blame” culture. All incidents will be investigated by trained personnel and,
where incidents are reported in a timely and open manner, the blamelessness will normally be
presumed, and disciplinary action will usually be the exception. If any disciplinary or administrative
action is needed, this will not be done without a proper investigation and a full review of the findings
of that investigation. Nevertheless, the following serious failures of personnel to act responsibly will
still attract sanction:
a.
Premeditated or intentional acts of damage to equipment or property.
b.
Actions or decisions involving recklessness which no reasonably prudent person,
with relevant training and experience, would take.
c.
Failure to report incidents as required by this policy
All personnel in Defence aviation, whatever their role, must recognise that they have a part to play
and a responsibility to participate actively in the process of attaining the highest flight safety
standards. Effective error management will enable Defence aviation to meet operational
requirements efficiently while ensuring the highest possible Air Safety standards. It will drive errors
to a low level whilst recognising that people will make mistakes, and the Just Culture will provide
every possible support to personnel to meet this goal.
All those involved in Defence aviation activities must:
- Recognise that professionals will occasionally make mistakes.
- Recognise that even professionals will develop unhealthy routines of behaviour.
- Be intolerant of reckless conduct.
- Recognise that inappropriate blame gets in the way of error management.
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- Expect that errors will be reported.
- Accept that we are all accountable if we choose to take risk.
- Expect that safety standards will improve if we manage errors effectively.
- Believe that when something goes wrong all will be treated fairly and with complete integrity
while we investigate whether mistakes have been made, and why, in our collective efforts to
get things right for the next time.
All those involved in Defence aviation activities have a duty to:
- Raise your hand and admit ‘I have made a mistake’.
- Raise your hand when you see risk.
- Manage risk at the appropriate level.
- Avoid and be intolerant of reckless behaviour.
- Encourage uninhibited reporting without fear or embarrassment.
- Actively participate in the error management reporting process in order to help create a
learning culture.
- Understand clearly the ‘red line’ between acceptable and unacceptable behaviour.
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CONTEXT – HEINRICH’S ICEBERG MODEL
In the 1930s, the American scientist H W Heinrich observed that for every fatal accident in complex
hazardous activities, there are about 30 events leading to major injuries, 330 that result in only
minor injuries, and approximately 600 where the consequences are negligible or non-existent – but
that the causes and contributing factors are all related. We currently investigate the fatal and major
accidents in great detail, and learn lessons – but only after the fact. If we can learn from the 600
‘near misses’, then we may be able to prevent major incidents in future. Error management
systems – and the DAEMS project – aim to help us to do so by encouraging people to report
problem situations before they lead to serious outcomes.
CONTEXT – SAFETY CULTURES
Reporting Culture: an organisational climate where people readily report problems, errors
and near misses;
Just Culture: an atmosphere of trust where people are encouraged, and even rewarded, for
providing safety-related information; and it is clear to everyone what is acceptable and unacceptable
behaviour;
Flexible Culture: a culture that can adapt to changing circumstances and demands while
maintaining its focus on safety;
Learning Culture: the willingness and competence to draw the right conclusions from its
safety information and the will to implement major safety reforms.
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ONE-LINERS
DAEMS is not an IT system, but a combination of policies, processes and tools for reporting and
analysing errors and near misses in Defence aviation.
An error management system is a powerful tool used as part of an Air Safety Management System.
The DAEMS project is an MOD-wide initiative to promote better air safety and operating efficiency
by better occurrence reporting, better investigation and better lessons learned.
Error is a normal part of any human activity – but if we know where mistakes are likely then we can
protect against their consequences.
Errors include system failings, such as manning shortages, inadequate equipment, or ambiguous
publications, as well as mistakes by individuals.
The DAEMS programme aims to improve Air Safety through active safety leadership and positive
safety culture development.
The DAEMS programme will develop a generation of aviation safety personnel who understand the
nature of human error and its causes, and are willing and competent to develop the desired safety
behaviours to deliver system performance improvements.
Error management systems – and the DAEMS project – aim to help us to prevent future accidents
or incidents by encouraging people to report problem situations or near-misses before they lead to
serious outcomes.
Error management systems provide a way to report and manage those potential issues that could
become a link in an accident chain.
Successful error management systems enable us to maximise our ability to identify, mitigate and
manage risks by involving everyone in the reporting and analysis of potential hazards, system
failures and human errors, in order to prevent recurrences.
Effective error management will enable Defence aviation to meet operational requirements
efficiently while ensuring the highest possible Air Safety standards.
Effective error management will drive errors to a low level whilst recognising that people will make
mistakes, and the Just Culture will provide every possible support to personnel to meet this goal.
Effective error management will enable us to improve our Air Safety reporting and management.
Open and honest reporting of hazards, near misses and mishaps allows us to learn from our
mistakes, both individually and corporately.
Open and honest reporting is the life-blood of Air Safety management.
Just Culture – the assurance that if things go wrong personnel will be treated fairly and consistently,
and will only be disciplined if they clearly had malicious or selfish intent.
Anybody who makes or identifies honest errors can feel able to report them without unwarranted
fear of harm to their career or personal standing.
EMS – the culture for improving Air Safety.
Error reporting – play your part in improving Air Safety.
Close call ? Let us know, so your near-miss doesn’t become someone else’s mishap.
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