ICAO European Region Aviation Safety Seminar April 5-7, 2006 Baku, Azerbaijan AZANS

Safety Management System Two basic reasons for Safety Management System: Civil Aviation is an example of High-Risk&High-Reliability organization Promoting competitiveness through high-performance

ATM related accidents/incidents No event 1994 1995 1996 1997 1998 1 Civil ATC 66 56 53 55 69 2 Mil ATC 3 VFR&IFR 19 12 8 14 29 4 Civil crew 15 28 17 24 20 5 Mil crew 6 7 GAT 30 27 26 18 Civil military coordination 13 9 10 Civil-civil coordination 16 Others Not defined 34 40 41 82 Total of ATM related 59% 46% 43% 45%

“Just Culture” Composition of collective behaviors and engineered work processes, that: recognizes the dynamic and systemic relationships between workers and their environment, seeks to reduce the risks of operational error and uncertainty through a shared-mindset that is focused on: a) inclusion, b) participation, c) forward-thinking

“Just Culture” Technical discipline as the basis of safety systems State of organizational maturity based on measured values to manage organizational behavior and work processes

“Just Culture” Safety Culture is: Static, Pervasive, Understood, Practiced uniformly by everyone in the organization Continuous process Learning process

Errors in ATM ACTIVE ERROR LATENT ERROR Skill based Technical Rule based Organisational Knowledge-based

TITANIC Engines were stopped and ship steered away from the iceberg ACTIVE ERRORS Engines were stopped and ship steered away from the iceberg Ship was operated at too high speed

TITANIC Latent errors Inadequate number of life boats No transverse overheads on bulkheads with watertight doors No crew training on practice cruise No training for officers to operate large single rudder ship Only one radio channel

Adam&Eva Active error: Rule based error a) wrong situation assessment and choosing incorrect ecision b) Not qualified for this task Latent error: Technical: a) Software design flaw Organizational: a) culture b) procedures c) leadership decisions

Characteristics of effective safety culture in nuclear industry The safety culture program is championed by leaders who sets an example A safety ethic or mindset is the overriding priority Ethical and truthful - people doing the right thing at the right time for the right reasons Has open and truthful communications at all levels Promotes a questioning attitude Recognizes that excellence is not a destination, it's a journey Self-critical with the goal of continuous learning and continuous improvement Results-oriented and holds the appropriate individuals accountable Its concerned with accident prevention, hence its proactive, rather that reactive Recognizes that regulatory compliance is the ground level you are to be standing on, not a wall to be climbed over

Problems Just culture versus Judicial system Accountability and non-punitive system Judicial system is anything BUT JUST What is needed is middle ground — a culture that holds people accountable for their actions while supporting a safe reporting environment.

Problems Changing system or us? Employee Mindset Employees are Forward Thinking, anticipatory, and prepared for contingencies Employees have a questioning attitude Employees feel comfortable raising issues Employees feel included Employees have strong organizational commitment Employees are willing to accept accountability and responsibility. Employees focus efforts beyond compliance

Conclusions Questions????? Just Culture - Easy task? Not at all. “We are what we repeatedly do. Excellence, then, is not an act but a habit” Aristotle