1. Achieving a Safety Culture in Aviation
Patrick Hudson
Leiden University

2. Contents Safety Management in aviation
Safety Culture - the added extra
The Evolution of Culture
Acquiring and maintaining a Safety Culture
Conclusions

3. Aviation Safety Management
Aviation has traditionally been managed from on high
Regulations (SARPs) have been classic prescriptive regulation - Tell What To Do
Progress was based on response to accidents
Fear of the consequences has kept people sharp
There were no requirements for processes
Aviation’s performance has been poor outside of Hull Loss measures

4. Improvements in Safety Performance
Technology
Engineering
Equipment
Safety
Compliance
Numbers of Incidents
This slide is taken from the Improving Supervision brochure and is intended to show that there are various ways of improving safety performance and that tackling technology and standards and HSE systems usually comes first but in order to continuously improve the softer behavioural stuff must be tackled too.
Presenter Notes
This slide shows a smoothed out version of the safety performance for Shell and other major Oil and Gas companies. It shows significant improvements in safety have been made through improved hardware, technology and design, with the next breakthrough coming through embedding management systems and improved procedures. To breakthrough the remaining plateau requires building a strong safety culture. A key element in doing this is changing peoples behaviours and attitudes to be more safety focused, which is why supervisors are so important because their position means they can have the most influence on their crews.
Time

5. 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

6. It doesn’t get better 2001

7. Are Airlines safe?
Hull loss statistics imply that most airlines are very safe for passengers
Injury statistics suggest that airlines are quite dangerous for their employees
Do airlines take safety seriously, or only the avoidance of extreme outcomes?
If they only go for avoidance, how advanced is their safety culture?

8. Are Airports safe? Runway incursions are a major problem
Analyses of the underlying causes show that a lack of effective safety management is at the basis of incursion incidents
Baggage handling is another source of injuries
Most organisations do not even know their injury rates

9. Safety Management Systems
ICAO has recently mandated Safety Management Systems (SMS)
Annex 6 (also 11 and 14)
JAR OPS 1/3.037
I proposed in 1997 that the combination of SMS and Safety Culture could achieve the target of two orders of magnitude improvement in safety performance

10. Improvements in HSE Performance
Technology
Systems
Engineering
Equipment
Safety
Compliance
Numbers of Incidents
This slide is taken from the Improving Supervision brochure and is intended to show that there are various ways of improving safety performance and that tackling technology and standards and HSE systems usually comes first but in order to continuously improve the softer behavioural stuff must be tackled too.
Presenter Notes
This slide shows a smoothed out version of the safety performance for Shell and other major Oil and Gas companies. It shows significant improvements in safety have been made through improved hardware, technology and design, with the next breakthrough coming through embedding management systems and improved procedures. To breakthrough the remaining plateau requires building a strong safety culture. A key element in doing this is changing peoples behaviours and attitudes to be more safety focused, which is why supervisors are so important because their position means they can have the most influence on their crews.
Integrating HSE
Certification
Competence
Risk Assessment
Time

11. HSE Management System A framework for HSE Management in Shell
Alcohol
& Drugs Policy
Audit
Plans
Road Safety
Plan
Safety Drills
Security
Policy
HSE
Continuous
Improvement
Policy
Mgt.
policy
link
Process
Safety (HSE Cases)
Task
No Structure
Structure

12. Safety Management Systems
Safety Management Systems are about operating with a systematic approach
The hazards are identified
The controls are in place
Assurance can be provided with a Safety Case
SMS in aviation is an ICAO standard (Annex 6)
ATC 2004
Aerodromes 2005
MRO’s 2008
Airlines 2009

13. Safety Culture

15. Here are some extracts from the Investigation Report …

16. “ The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture….
…Cultural traits and organizational practices detrimental to safety were allowed to develop, including:
reliance on past success as a substitute for sound engineering
organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion …”

17. BP - Texas City
BP’s Texas City refinery had a major explosion on March 23rd 2005 of the isomerization plant
15 dead, 170 severely injured, >500 wounded
More than $ 700 M set aside for compensation and $ 1000 M for remediation & improvement
Not including lost production
Texas City had a refining production of about 460,000 bbl per day and has been operating at half capacity

18. BP Analysis of Texas City
Most attention paid to what happened and how (Investigation)
But, the report distinguished between (Analysis)
immediate causes (What happened?)
management system causes (Why did it happen?)
cultural issues (How was it allowed to happen?)
Mogford report set a new standard in Safety Investigation and Analysis

19. BP’s Own Analysis Immediate causes
Violations by individuals and supervisors
Lack of knowledge of hazards present
Poor decision making
Seen as routine activities
Defective safety devices
Inadequate equipment
Cultural issues
Poorly motivated workforce, behaved in a disempowered way
Lack of enforcement of following procedures
Lack of role models at supervisor and superintendent levels
Little expectation of behaviours and performance
No consequences of good or bad performance
Fear to challenge and say “no”
Lack of teamwork evidenced by many behaviours and attitudes

20. Similarities between BP and Shell study
In BP
- Management where I work listens to my ideas for improvement
- My line manager/team leader treats me fairly
- My line manager/team leader would support me if I needed help in handling tensions between my work and personal life
- My pay is linked to my performance
In Shell
I am satisfied with my involvement in decisions that affect my work
Where I work, we are treated with respect
My team leader coaches me effectively
My team leader supports me in balancing my work and my personal life
I believe what leaders in my organisation say
I get a clear sense of my organisation's direction from my leadership team
The factor “Management Support” is composed of the following questions of the People Assurance Survey and the interesting thing was that Shell found similar results and looking at other researches in this matter of leadership support we found that Gallup got to the same conclusion and developed a survey called Gallup12 to enhance productivity

21. Culture is a basic issue in all these accidents
Our culture determines what we regard as important
Our culture determines what we see as normal and acceptable
Culture acts as a multiplier on all safety elements
Plant - equipment
Process
People

22. Safety Culture The Added Ingredient
Safety Management Systems and Safety Cases provide a systematic approach to safety
Safety Management systems are still driven by paper
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

23. Improvements in Safety Performance
Technology
Systems
Behaviours
Leadership
Accountability
Attitudes
HSE as a profit centre
Engineering
Equipment
Safety
Compliance
Numbers of Incidents
This slide is taken from the Improving Supervision brochure and is intended to show that there are various ways of improving safety performance and that tackling technology and standards and HSE systems usually comes first but in order to continuously improve the softer behavioural stuff must be tackled too.
Presenter Notes
This slide shows a smoothed out version of the safety performance for Shell and other major Oil and Gas companies. It shows significant improvements in safety have been made through improved hardware, technology and design, with the next breakthrough coming through embedding management systems and improved procedures. To breakthrough the remaining plateau requires building a strong safety culture. A key element in doing this is changing peoples behaviours and attitudes to be more safety focused, which is why supervisors are so important because their position means they can have the most influence on their crews.
Integrating HSE
Certification
Competence
Risk Assessment
Culture
Time

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

25. 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

26. The HSSE Culture Ladder
GENERATIVE (HRO)
HSE is how we do business
round here
PROACTIVE
Safety leadership and values
drive continuous improvement
Increasingly Informed
CALCULATIVE
We have systems in place to
manage all hazards
REACTIVE
Safety is important, we do a lot
Increasing Trust and Accountability
every time we have an accident
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
PATHOLOGICAL
Who cares as long as
we're not caught

27. Safety Culture
“A good safety culture is the embodiment of effective programs, decision making and accountability at all levels.
When we talk about safety culture, we are talking first and foremost about how managerial decisions are made, about the incentives and disincentives within an organization for promoting safety.
One thing I have often observed is that there is a great gap between what executives believe to be the safety culture of an organization and what it actually is on the ground. Almost every executive believes he or she is conveying a message that safety is number one. But it is not always so in reality.”
Carolyn W. Merritt - U.S. Chemical Safety and Hazard Investigation Board November 2005

28. So what does a Generative culture look like
So what does a Generative culture look like? The High Reliability Organisation (HRO)

33. World Champions 1904 ?
How do they do it? ?

35. The Generative Organization
Low profile - always to be relied on
Low accident rate - but there is always bad luck
Active involvement and accountability for all
Workforce initiative in safety and operations
Short and effective feedback lines
Procedures under constant scrutiny
Training, cross-training and more training
Benchmarking against others, inside and out
Obsessive planning - many scenarios create requisite variety
Willing to try new ideas, but accept the risk of failures
Chronic Unease
Can be equated with the High Reliability Organisation (HRO)

36. Safety cultures allow taking risks Taking risks makes money
Safety management can only manage standard hazards
Safety cultures take more account of the hazards and ways of living safely
This enables them to operate closer to the edge
Return on capital is a function of risks taken
Safety cultures are not reckless
This is the advantage

37. The Edge The Edge Normally Safe Inherently Safe Return on Capital 6%
No need
Return on
Capital
Invested 6% 9%
12%
Normally Safe
The Edge
Safety Management Systems
Safety Culture

38. How to create a Safety Culture
Depends on where you are starting from - you don’t get to the end in one step, unfortunately, all the steps have to be traversed
Becoming a Safety Culture involves acquiring and then maintaining a set of skills
The two major factors are informedness and trust, so these have to be developed
Be systematic (Safety Management Systems are a start) and then learn to operate with the unknown as well

39. Creating a Safety Culture II
Have the program run right from the top - It’s the CEO’s pet project
Appoint a senior champion who is dedicated and willing to stick it out, even when it gets hard
The champion reports direct to the CEO and the board
Recognise that it will be uncomfortable, safety cultures are different, not just an add-on

40. Which drivers for which culture?
Pathological respond to regulation
They don’t know the rest or it won’t happen anyway
They may be shifted if they are confronted with the costs
Reactive respond to ethics, laws, regulation and accident costs (everything!)
Calculative respond to regulation
They may be ethical but regulations and systems are they way they succeed
Proactive respond to costs (as lost benefits)
Regulations are seen as defining minimum requirements
Generative respond to benefits and self-image
They see it as strange if you don’t have HSE as a priority

41. Developing a Safety Culture: Informed and Learning
Agree on ways to analyse incidents to reveal 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 all incidents are worth reporting
Experiment with changes when new information comes in, don’t be afraid to admit failure first time round
Practice management in wanting to know from near misses before they become accidents

42. 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

43. Developing a Safety Culture: Wary
Most dangerous situations can be planned for
Planning is never a bad thing, but
Your remaining problems arise from what you never thought of or considered, so:
Construct systems that can cope with the unexpected
Practice Chronic Unease
Chronic Unease means moving from
“We haven’t had an accident, aren’t we doing well” to
“We haven’t had an accident, what are we overlooking? life isn’t that fair”

44. Developing a Safety Culture: Flexible
Develop a workforce that is more than ‘just’ competent - multi-skilling is easier or even necessary in smaller airlines
Move control down as far as possible
Develop the possibilities for ‘variance procedures’ where operations are defined by what is safe and sensible
Risk assessment of ongoing activities
Competence defined limits on freedom to act
Lots of communication when there are differences

45. Maintaining a Safety Culture
The greatest enemy is success - complacency is easy
If you find yourself saying “Now we can get back to the real business” you have lost it
Keep maintenance as a target in its own right
Keep close to the hazards
The most effective way to stay awake is to stay scared
If you can’t find your own accidents, go find someone else’s
Never let up

46. Safety Culture The values of an Organisation
Safety culture determines performance as well as safety
The culture is expressed by all parts of the organisation
Flight deck
Cabin crew
Maintenance
Ground staff
The cabin staff and check-in personnel provide the main indication of the culture to the paying public
The Australian Defence Force has explicitly stated that it wants to become Generative

47. Challenges to Safety Culture
The overall culture itself is a source of problems
Regulators can create legal barriers if their own culture is less advanced
Management can lose their nerve and promote the champions away
Change is hard and the status quo comfortable

48. Why Don’t They?
Organisational cultures are only capable of understanding the world in ways appropriate to their current safety culture level and their readiness to change
Less advanced cultures just don’t understand that it’s better up there!
Counter-pressures exist to force organisations back towards the Calculative
The Generative represents a vast leap into the unknown
The alpine metaphor, you see the mountain top from where you are looking. When you breast the ridge, you can see the next peak to climb (Mont Blanc)

49. Conclusion
Safe organisations make money where others do not dare to operate
Safety cultures have increased trust (and lower costs)
From management to workforce
From workforce to management
Airlines, airports and Air Traffic Control can implement Safety Management Systems and then develop generative organisations 32