Job Smeltink, Sybert Stroeve and Barry Kirwan Advancing safety in organisations Application via the Luton Stack Job Smeltink, Sybert Stroeve and Barry Kirwan Header&footer aanpassen: ga naar ‘insert’ en klik op ‘header & footer’.

Content Organisational accidents Improving safety in organisations: Future Sky Safety P5 project Luton Safety Stack What we have learnt Key takeaways

Organisational accident Shift towards organisational factors Term popularised by James Reaso (1997) Organisations lay conditions for errors, behaviour, workarounds Organisations in aviation have implemented SMS SMS structured around compliance: bureaucracy, paper

- Bill Voss (Aerosafety World, May 2012) ‘The ICAO guidance was built around the “four pillars,” so now everybody has an SMS with four pillars. And of course, now every regulator has a checklist that counts the pillars. We all have policies, posters, forms, processes and meetings. This is all really very comforting to people who have never grasped the concept of risk management. They are reassured by the fact that all they really have to do is fill out the right form and show up at the weekly meeting. Many well-meaning operators have worked themselves into a position where they are spending lots of time and money, but are not necessarily getting the intended results.’ - Bill Voss (Aerosafety World, May 2012) Title of presentation, date

Organisational accident SMS structured around compliance: bureaucracy, paper A lot of guidance on “hard” SMS elements “soft” factors, informal, human-related elements, context depending,

05 September 2019

Future Sky Safety P5: Resolving the organisational accident 05 September 2019 Future Sky Safety P5: Resolving the organisational accident Eurocontrol, NLR, Deep Blue, London School of Economics, Trinity College Dublin, FOI KLM, ENAV, Airbus, Boeing

FSS P5 Challenges How do you ensure safety leadership from the top? How do you include all of this in your SMS? How do you ensure organisational focus is on the right issues? How do you work together with other organisations in a major crisis? How do you maintain safety focus through the middle? How do you ensure rapid sharing of safety intel at the sharp end? How do you ensure the right safety and just culture?

FSS P5: 4 research areas, 1 on integration WP1 – Safety Intelligence (leadership) Top managers & Middle managers WP2 – Safety Mindfulness (sharing of safety information) Middle managers & Operational staff WP3 – Safety Culture WP4 – Agile Response Capability WP5 – Advanced SMS Application cases: how it works in practice.

FSS P5: some results

FSS P5: some results

FSS P5 results: toolbox (SAFEORG.EU)

Safety Culture in FSS P5 Major survey with European pilots: 7200 replies Survey with Airbus Design and Boeing Europe Surveys with easyJet and Luton Airport Survey with KLM in 2017 Luton Safety Stack in 2017

Overall M = 3.49

Survey Conclusions Colleague commitment to safety (4.06) Speaking up (3.85) Risk Handling (3.77) Procedures & Training (3.73) Just culture and Reporting (3.71) Communication and Learning (3.71) Collaboration and Involvement (3.60) Management commitment to safety (3.44) Staff and equipment (3.44) Fatigue (2.82) Perceived Organisational Support (2.65). Overall, the average safety culture is good. This was not a ‘grievance survey’. However, standard deviations were high The most worrying result is fatigue. Pilots are concerned it is affecting their performance, and >50% feel their companies do not take the fatigue issue seriously Those pilots on unsecure contracts, Cargo and Low Cost airlines generally had poorer safety culture The EC, regulators, airlines and pilot associations need to consider the results and determine ways forward

Press coverage of survey Press focused on the negative aspects such as Fatigue and atypical contracts. Economist was the most balanced article (8th December)

“SAFETY CULTURE STACK” ATM AIRPORTS “SAFETY CULTURE STACK” AIRLINES MANUFACTURERS MANUFACTURERS

The Luton Airport Safety Stack

12 organisations now working together on improving safety

5 September, 20195 September, 2019

5 September, 20195 September, 2019

What we have learnt (1/3) The safety culture process appears to work and be useful in each aviation segment Each organisation being safe on its own is good, but we can raise our game, fast-tracking safety learning, and overcoming each other’s blindspots The Safety Stack is inter-organisational, spreading safety culture across traditional (and even competitive) boundaries safer through sharing

What we have learnt (2/3) Initial assessment Workshop to establish areas for improvements Choose right intervention Implement / monitor Initial assessment: SMS maturity or Safety Culture -> identify strong and weak points Involvement of operational personnel (workshop) to link results to operational issues Sharing experiences and views helps to get good solutions

What we have learnt (3/3) Improving safety lies in advancing informal, human-related, soft elements Need to understand how the organisation works (context) Involvement of operational personnel - link to safety issues Participation not free of engagement – have enough influence

Key takeaways Focus on soft elements of SMS Look at the practice not on paper: context is important No one-size-fits-all Aligning processes, information and safety views Initial assessment starting point for addressing safety issues Interfaces between organisations Sharing experiences (peer to peer)