Safety Culture Informed, Just and Fair Patrick Hudson ICAO/Leiden University April 2006 ICAO Seminar Baku

Structure How safe is aviation? Safety culture The elements of a safety culture The need for a Just Culture Why it is complicated? What if it goes wrong? Conclusion April 2006 ICAO Seminar Baku

April 2006 ICAO Seminar Baku This slide is intended to show that there are various ways of improving safety performance and that tackling technology and standards and safety systems usually comes first, but in order to continuously improve the softer behavioural stuff must be tackled too. This is what constitutes Culture, which addresses the ‘softer’ human issues, but also multiplies the effectiveness of the technology and management systems. April 2006 ICAO Seminar Baku

How Safe is Aviation? Hull losses are low, we are worrying about the effect of increased exposure at current levels of flight safety But is the aviation industry safe or is it just safe for passengers? April 2006 ICAO Seminar Baku

Aviation isn’t that safe US data — 1997 Lost Workday Incidents per 100 Employees in US 9 8 7 6 5 4 3 2 1 DuPont Chem Industry Aircraft & Parts Mining Construction Logging Steel Foundry Trans by Air 0.03 1.1 5.3 8.4 Industry Average (2.1) 5.5 3.6 2.9 1.6 Frequency Rate Shell LTIF = 0.7/m = 0.14 OSHA Courtesy DuPont April 2006 ICAO Seminar Baku

It doesn’t get better - 2001 April 2006 ICAO Seminar Baku

Safety Culture The Added Ingredient Safety Management Systems provide a systematic approach to safety 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 April 2006 ICAO Seminar Baku

Safety Culture indicators chronic unease safety seen as a profit centre new ideas are welcomed GENERATIVE resources are available to fix things before an accident management is open but still obsessed with statistics procedures are “owned” by the workforce PROACTIVE we cracked it! lots and lots of audits HSE advisers chasing statistics CALCULATIVE 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 REACTIVE Safety Culture Ladder well researched definitions calibrated questions on laminated cards to assess status can be used at all levels in the organisations can be used to identify differences (perceptions) at various levels in the organisation can be used to identify differences between parts of the organisation can be used to assess progress over time: where were we, where are we, where do we want to be Starting point for putting HSE improvement on the map. Do tests (see last slide for meaning of background colours) If you want to reach a higher level it is also necessary to assess the readiness to change. PATHOLOGICAL the lawyers said it was OK of course we have accidents, it’s a dangerous business sack the idiot who had the accident April 2006 ICAO Seminar Baku

The Evolution of Safety Culture GENERATIVE safety is how we do business round here Increasing Informedness PROACTIVE we work on the problems that we still find CALCULATIVE we have systems in place to manage all hazards REACTIVE Safety is important, we do a lot every time we have an accident Increasing Trust & Accountability PATHOLOGICAL who cares as long as we’re not caught April 2006 ICAO Seminar Baku

April 2006 ICAO Seminar Baku

Characteristics of a Safety Culture Informed - managers know what is really going on Reporting - the workforce is willing to report their own errors and near misses Just - a ‘no blame’ culture, with a clear line between the acceptable and unacceptable Wary - ready for the unexpected Flexible - operates according to need Learning - willing to adapt and implement necessary reforms April 2006 ICAO Seminar Baku

How to create a Safety Culture Depends on where you are starting from - unfortunately you can’t get to the end in one go, all the steps have to be traversed Becoming a Safety Culture involves acquiring a set of safety management skills and then maintaining them The two major factors are informedness and trust, and these have to be developed over time Be systematic (Safety Management Systems are a start) and then learn to operate with the unknown as well April 2006 ICAO Seminar Baku

Developing a Safety Culture: Informed and Learning Agree on ways to analyse incidents to reveal both 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 incidents are worth reporting Practice management in wanting to know from near misses before they become accidents April 2006 ICAO Seminar Baku

A Reporting Culture In order to get the information we need, we need to be told This often requires people to admit their own errors - this is personally difficult at best The workforce will not tell what they have done if they are afraid of the consequences Pathological and Reactive cultures “shoot the messenger” Generative organisations train messengers! April 2006 ICAO Seminar Baku

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 April 2006 ICAO Seminar Baku

Why is Blame so easy? April 2006 ICAO Seminar Baku

Human Error - The Problem If an accident happens people want to blame someone Insurance - who pays? Criminal responsibility - who goes to prison? Technical failures are usually seen as less reprehensible This often applies even with near misses April 2006 ICAO Seminar Baku

Blame Blame is something that is attached to individuals What about objects? What about non-human entities? Blame is associated with causality People attribute cause to other people Bad people have bad accidents April 2006 ICAO Seminar Baku

Attribution Fundamental Attribution Error Individuals attribute causes of their own actions to external causes They attribute causes of the actions of others to personal factors in those individuals There is a belief that The World is Just This leads to the idea of accident proneness Bad things happen to bad people Also called Outcome bias April 2006 ICAO Seminar Baku

Hindsight Bias Hindsight Bias (Fischhoff, 1975) One knew it all along Known branches are over-estimated We now know the outcome, we didn’t before The scenario now seems easy to generate and therefore was easy before the event In advance, bad outcomes are evaluated as less likely, especially if you feel you can control matters If you knew the best options, and could have controlled for them, then selecting any other must be incompetent! April 2006 ICAO Seminar Baku

The Illusion of Free will People believe they have free will They can always choose what they will do They can foresee the consequences of their actions and act accordingly They attribute this to others They commit the fundamental attribution error Hindsight bias makes the choices seem less and more obvious than at the time They regard human failures as more avoidable than technical failures April 2006 ICAO Seminar Baku

The Law - Prosecution Prosecutors are tasked with finding one or more individuals to prosecute Prosecutors will only proceed if there is a reasonable chance of success The closer to the event the harder the evidence The further from the event, the more doubt can be introduced about alternative causes Any amount of specific evidence may be sufficient in a criminal case April 2006 ICAO Seminar Baku

Corporate Manslaughter Targeting company bosses is the new approach Based on a duty of care concept - bosses have a duty to ensure safety Lord Denning defined the Guiding Mind principle This has proved hard to obtain prosecutions The principle of Executive Authority makes it easier to prosecute (When the executive says jump, subordinates ask how high, not vice-versa) April 2006 ICAO Seminar Baku

Who is convinced? Prosecutors Police Investigators Judges Juries (in jury systems) Colleagues The accused themselves April 2006 ICAO Seminar Baku

Thinking about a Just Culture The need to have rules and procedures The standard approach to non-compliance Marx’ and Reason’s Just Culture A new approach - Hearts and Minds Types of violation - Managing Rule Breaking Roles of those involved - Managers to Workers Individuals - the reasons for non-compliance Solutions - from praise to punishment From Just Culture to Fair Culture April 2006 ICAO Seminar Baku

The need for rules Many hazards cannot be controlled by hardware or design Other hazards are more easily controlled by administrative approaches There are three levels of specification Guidelines Descriptions and sequences Work instructions Failure to follow procedures temporarily negates the control of the management system The assumption is that all the rules will be followed April 2006 ICAO Seminar Baku

The Simple View - How to manage non-compliance Rules and procedures are there for a purpose Personnel are expected to know them and are clearly expected to comply with all relevant procedures Failures to comply represent a deliberate failure of an individual’s performance contract Such failures cannot be tolerated, because the HSE-MS relies upon compliance Non-compliance is best managed by making people aware of the personal consequences, from written warnings to dismissal April 2006 ICAO Seminar Baku

Review of the Simple View There is an assumption that all rules and procedures are optimal and not in need of improvement The US Nuclear INPO studies found that 60% of procedural problems were due to incorrect procedures The requirement is for unquestioning compliance by a worker The INPO studies found that most people did follow procedures, even when they were incorrect A weaker version of such requirements may require challenge This is often based upon following the incorrect rule or procedure first, with subsequent challenge April 2006 ICAO Seminar Baku

The Just Culture - Version 1 Originated by David Marx - a Boeing engineer and also a lawyer Propagated by Prof James Reason Starts with assumption of deliberate violation (e.g. sabotage) by individuals (Marx found about 10%) Next employs the substitution test (would others have done the same?) to check for individual vs system blame If there is no evidence that an individual was reckless and there is no history of previous non-compliance, then define non-compliance as blame-free April 2006 ICAO Seminar Baku

April 2006 ICAO Seminar Baku

Review of Just Culture v.1 The model appears to assume individual guilt unless proven otherwise The drawing, going from left to right, implies visually where priorities lie. The amount of space devoted to discipline does the same There are only two points where management is required to remedy system problems identified, after the event. Most are concerned with distinguishing whether a worker should have more discipline or just be actively coached until they comply April 2006 ICAO Seminar Baku

The Just Culture - Version 2 Empirical studies of non-compliance showed a complex picture 6 different types of violation Managers and supervisors have a role as well as the violating worker Individuals will be working with a variety of intentions, from the company’s interest to their personal gain Solutions range from improving the system to ensuring compliance April 2006 ICAO Seminar Baku

Example DAL 39 An example of what happens today in Western Europe Criminal prosecution of three air traffic controllers All 3 found guilty of a misdemeanor at Court of Appeal No punishment because of the system failures, but no prosecution of management April 2006 ICAO Seminar Baku

DAL 39 A Delta 767 aborted take-off at Amsterdam Schiphol on discovering a 747 being towed across the runway Reduced visibility conditions (Phase - B) The tower controller was in training, under the tower supervisor There was another trainee and of the 11 people in the tower five were changing out to rest The incident happened between the inbound and outbound morning peaks April 2006 ICAO Seminar Baku

Runway Incursion (1998) April 2006 ICAO Seminar Baku Beschrijving incident. Lering: ZEER VEEL AANPASSINGEN: Procedureel (O.A rol supervisor / coach scheiden) Technisch (o.a. bedieningspaneel in de toren) April 2006 ICAO Seminar Baku

The DAL 39 event scenario Pilots see 747 Tunnel brought into use and abort take-off Tunnel brought into use without briefings Routine violation of tow procedures Airport decides to change airport structure Tower combining training and operations during difficult periods Controller gives clearance without assurance of tow position April 2006 ICAO Seminar Baku

Why did all this happen - 1? Tow was in violation, but this appears to be routine No clear protocols for ground vehicles and no hazard analysis Different language for aircraft (English) and ground vehicles (Dutch) Poor quality of ground radio Clearances appeared to be unlimited once given Tower supervisor was also OTJ trainer in the middle of the rush hour Altered control box not introduced to ATC staff April 2006 ICAO Seminar Baku

Why did all this happen - 2? No briefings about alterations at Schiphol (It has been a building site for years) Too many trainees in the tower in rush hour under low visibility conditions Differences in definition of low visibility between aerodrome and ATC No management apparent of the change in use of the S-Apron No operational audits by LVNL or Schiphol, of practice as opposed to paper Schiphol designed requiring crossing and the use of multiple runways for noise abatement reasons April 2006 ICAO Seminar Baku

Could this have been known in advance? Many problems are known in advance If no one tells they will certainly happen again If people fear prosecution and other consequences of admitting their errors, will they tell? Without reporting, we are doomed to wait until we have an accident that everyone can see April 2006 ICAO Seminar Baku

Learning from Errors requires Trust International oversight Safety improvements National Legislation Analysis Lessons learned Statistics Incident Reports Trust April 2006 ICAO Seminar Baku

What happens when prosecution takes place? After the DAL-39 case, ATCOs reduced the number of reports about ATC errors They continued to report pilot errors They were no longer being prosecuted April 2006 ICAO Seminar Baku

April 2006 ICAO Seminar Baku

What next? It became clear that a new approach was needed The old model was even found to be the cause of a major accident! All types of errors and violations need to be considered Positive reporting should be rewarded There are still actions that everyone agrees are unacceptable (Reckless, personal) April 2006 ICAO Seminar Baku

Shell’s new model Shell decided that the concept of the Just Culture needed to be extended To cover rewards for good behaviours To reflect the differences in types of violations and errors To highlight the responsibilities of both individuals who break the rules and their managers who condone or do not want to know April 2006 ICAO Seminar Baku

April 2006 ICAO Seminar Baku

Decision Flowchart April 2006 ICAO Seminar Baku

Consequences All actions now have consequences These apply both to the individual and their managers Distinguishing different types of violation is essential Everyone has to agree to the process and the consequences April 2006 ICAO Seminar Baku

April 2006 ICAO Seminar Baku

Conclusion Safety cultures make the difference between a mechanical application of SMS and full implementation that obtains the maximum benefits A Just and Fair Culture is essential for reporting Without reporting no one knows what is going on, until it is too late April 2006 ICAO Seminar Baku