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

2. 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

3. ATM related accidents/incidentsNo
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%

4. “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

5. “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

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

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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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