1. The European Organisation for the Safety of Air Navigation Safety Culture: Can we improve it? Barry Kirwan EUROCONTROL

2. Safety Culture in European ATM 2 Developing Change Proposals Changes that are effective in the organisation concerned Changes which are sustainable Changes which other ANSPs can learn from

3. The European Organisation for the Safety of Air Navigation Safety Culture Progress in AVINOR Chief executive ANS Knut Skaar

4. Safety Culture in European ATM 4 Reasons for Focusing on Safety Culture Flight-safety as a quality mark on our product Goal; no accidents and fewer serious incidents with ATM contribution Lessons learned from other industries The situation in Avinor when returning as as chief executive for ANS The benefit of working with the elements of Safety Culture.

5. Safety Culture in European ATM 5 Advancing Safety Culture in Avinor Feb 07- Survey Mar 07- Workshop What do we do with the results? Implementing measures in the areas that was identified as challenges and Building a Safety Culture campaign Oct 07- Roadshow (23 ATC units/11 CNS regions- some combined) Jan 09 - Summary after the Campaign, implement necessary changes April 09- New Survey.

6. Safety Culture in European ATM 6 Example High Level Insights from the Survey Process Incident reporting ‘impediments’, some easy to fix Significant regional/individual variations in attitudes to safety ‘Formal’ risk picture, and actual risk picture not the same: some vulnerabilities were obscured Talking with staff raised as many solutions as problems Need to talk to the whole organisation, not just controllers.

7. Safety Culture in European ATM 7 Informed Culture Just Culture Reporting Culture Learning Culture Flexible Culture ‘Pillars’ of Safety Culture (James Reason)

8. Safety Culture in European ATM 8 Informed Culture Just Culture Reporting Culture Learning Culture Flexible Culture AVINOR Approach, Post-Survey Dialogue, Involving all Personnel Improved Information Flow BuildingCompetence Understanding Regional Differences Better Risk Picture Re-assessing Priorities

9. Safety Culture in European ATM 9 Safety Culture Campaign – ANS Roadshow

10. Safety Culture in European ATM 10 What I Want to Know as Chief Executive... Do our ATCOs and Technical staff come to work aiming to deliver a safe service to the customers? Where can we improve? Do we have the right competencies and attitudes Correct risk picture? All the vulnerabilities of our system – Exercising sound judgement?

11. The European Organisation for the Safety of Air Navigation How much can we change in 2 -3 years?

12. Safety Culture in European ATM 12 Safety Culture – Second time around Kjersti Disen Avinor

13. Safety Culture in European ATM 13 Safety culture assessment second time around History First safety culture assessment 2007 Safety culture “Roadshow” Second safety culture assessment 2009 Way forward

14. Safety Culture in European ATM 14 Improvement Areas Exercising priorities Improving feedback after reporting Team-meeting places Improve management of change Relation to regulator.

15. Safety Culture in European ATM 15 Second Safety Assessment – 2009

16. Safety Culture in European ATM 16 Reporting & Learning Increases in favourable responses scores for items included in both the 2007 and 2009 survey

17. Safety Culture in European ATM 17 Communication Increases in favourable responses scores for items included in both the 2007 and 2009 survey

18. Safety Culture in European ATM 18 Second Safety Assessment – 2009

19. Safety Culture in European ATM 19 Improvements Committed and listening executive team Capable and competent safety team Empowerment of staff to take safety seriously Safety incident reporting system capable of handling and feeding back to staff Top down communication related to safety.

20. Safety Culture in European ATM 20 Challenges Large distributed organisation Resources remain constrained Standardising performance of supervisors Communication challenges Feedback of incident reports – still… Communication channels for engineers/ATSEPs Site wide communication events Sharing operational information between units.

21. Safety Culture in European ATM 21 Way Forward Conclude the ”roadshow” Activities to address the challenges identified Launch a second ”roadshow” Improvements to occurrence investigation and lessons learnt SMS-training Regular safety culture assessments.

22. Safety Culture in European ATM 22 Conclusion Very positive experience – especially the “roadshow” Assessment – worthwhile! Most important aspect – MANAGEMENT COMMITMENT! “The good results give us motivation to continue the work on improving the safety culture in Avinor!”

23. The European Organisation for the Safety of Air Navigation Can other ANSPs repeat this progress?

24. The European Organisation for the Safety of Air Navigation Meeting with Users Safety Culture at NAV PORTUGAL

25. Safety Culture in European ATM 25 MadridMadrid CasablancaCasablanca CanáriasCanárias ShanwickShanwick GanderGander New York PiarcoPiarco SalSal SANTA MARIA OCEANIC FIR SANTA MARIA OCEANIC FIR SANTA MARIA OCEANIC FIR SANTA MARIA OCEANIC FIR LISBON FIR LISBON FIR LISBON FIR LISBON FIR BrestBrest Airspace controlled by NAV Portugal, and adjacent FIR’s

26. Safety Culture in European ATM 26 Safety Management SafetyPolicyandPrinciples SafetyAssessmentMethodology SafetyManagementTools SafetyCOMMUNICATIONandTraining Target Level of Safety Organization Acountabilities Safety Letter Voluntary Reporting Presentations and Courses Classification Risk Analysis Schemes Safety surveys Safety audits Safety Analysis Model, Statistical Analysis of Radar Information. Safety Indicators SAFETY CULTURE SURVEYS

27. Safety Culture in European ATM 27 NAV Portugal SMS Guidelines for the Safety Culture’s evaluation.

28. Safety Culture in European ATM 28 Results of a Safety Culture Survey at NAV PORTUGAL Version: 3.0 Date: 30 April 2007 Safety culture : qualitative and quantitative assessment A Tale of Two Surveys (2007) Project Coordination: Sílvia Agostinho da Silva CIS/DEPSO/ISCTE/PORTUGAL silvia.silva@iscte.pt

29. Safety Culture in European ATM 29 NAV-P Strong points 1.High concern with safety 2.Participants’ declared values in line with the company's safety policy 3.NAV safety climate very positive, characterised by a perception that safety objectives and rules are valued, that work is conducted safely even under pressure, and that lessons are learned from accidents at work 4.Very positive perceptions of the safety climate in the working groups, in relation to actions by both management and colleagues. 5.Perception that all staff are involved in safety. 6.Satisfaction with safety

30. Safety Culture in European ATM 30 Improved change management Management leadership on ‘learning not blaming’ Sharpening the focus of the incident reporting and learning process Better communication on the role of the Safety Department A task force to consider the best ways to manage safety in high capacity situations Areas for Improvement

31. Safety Culture in European ATM 31 Reducing NAV-P’s Negative Safety Culture ‘Footprint’

32. The European Organisation for the Safety of Air Navigation Regional Workshops

33. Safety Culture in European ATM 33 Regional Workshop - 14/15 December Paris Who Attended ROMATSA NATS BELGOCONTORL AVINOR ENAV SLOVENIA CONTROL IAA NAV-P ARMATS MUAC EUROCONTROL

34. Safety Culture in European ATM 34 Regional Workshop - Knowledge Sharing Agenda ANSP Presentations 6 ANSPs shared safety information Workshops Learning from incidents The role of the Supervisor Just Culture Communication

35. Safety Culture in European ATM 35 Workshop – Output Supervisors Few ANSPs have defined roles for Supervisors Not management – Not Controllers Can make a bad day a lot easier Can make a bad day a lot worse Large variation between supervisors Define competencies – behaviour based Use to create recruitment profile Co-locate with Engineering supervisor Use 360 degree feedback to address performance issues Build in Safety Responsibilities

36. Safety Culture in European ATM 36 Regional Workshop - Deliverables

37. Safety Culture in European ATM 37 Conclusions The approach can improve safety culture, both at a general level, and at a more ‘tactical’ level. A light ‘peer pressure’ is emerging in Europe, with a sharp increase of participating countries in 2010. This is at least in part due to ANSPs sharing the experience that safety culture is not ‘fluffy’ and vague, but can in fact fix real problems and improve safety and safe performance. We’re all trying to learn how to do it better.