Safety Culture What it is and the Six steps Necessary to Achieve it

Safety Culture What it is and the Six steps Necessary to Achieve it WHERE SAFETY COMES FIRST ! Presented at Flight Safety Foundation Business Aviation Safety Summit Montreal, PQ April 11, 2013 Presented by Gordon Dupont

Safety Culture Is a lot more than a sign Safety First Unless it costs money Unless it costs money Unless it costs money it costs money

What is Safety? The state of being Safe The condition of being Safe from undergoing or causing hurt, injury or loss Webster’s Dictionary The risk (odds) of something causing you grief is As Low As Reasonably Practical (ALARP) G. Dupont

What is a Safety Culture? It is a Culture where: Safety is treated seriously by the management and all employees Safety goals are set and all work toward their achievement all company employees are trained and encouraged to think and work Safely at all times a system is in place to report Safety concerns all believe that Safety does not have to come at the cost of productivity or profit Safety is an integral part of the way the company operates The company has a framework to accomplish all of the above –A Safety Management System (SMS) Gordon Dupont

Why is a Safety Culture so important now? The probability (risk) of being killed in an aircraft accident varies from 1 in 260,000 (Africa) To 1 in 11,000,000 (45 million 2012 USA) A difference of 42 times better Why? A Safety Culture makes a difference

50 Major Fatal Airline Accidents per year Airline Aircraft in service 45 25,598 40 35 12,595 30 25 1997 2016 20 We must continue to do better s e n si u B Hull loss accidents per year s a s al u us With HF Training And a Safety Management System 15 10 Millions of departures 5 0 Hull loss accident rate 1965 1975 1985 1995 Year 2005 2015 Boeing Aircraft Corporation By 2016 there will be one major fatal accident per week somewhere in the world

What does a Safety Culture look like? You’ll Know it When You Work in it It is very difficult to measure accurately It is seen by the way things are done around the organization It is heavily influenced by management It is constantly changing

A Safety Culture must have the 3 “C’s” C ommitment Management’s True motivation and allocation of resources C ompetence Knowledge to know how to achieve the organization’s Safety goals C ognizance Awareness that it is a never ending battle Mintzberg

The Six Steps to a Safety Culture 1. JUST culture James Reason Gordon Dupont

Step 1 A Just Culture A Just Culture is the foundation of any Safety Culture Where “Honest & At-Risk” At-Risk mistakes do not result in discipline Where an Administrative policy spells out “Reckless Behaviour” Where persons can admit to an error without fear of punishment Screw up and you’re history

But what about Discipline? What is the real purpose of discipline? REVENGE? Holding the Person Accountable TO BE SEEN TO BE DOING SOMETHING? TRADITION? To ensure an occurrence does not happen again th i w a fi a M ts e o h o t b y t Onl cemen er their e a harsh cy hav line poli son d p r i a c ic h dis R e l l se Gi

If only they all wore hats

Degree of Discipline X Was the act deliberate with a reasonable knowledge of the possible consequences? X Has the person made similar errors in the past? X Do they accept responsibility for their actions?

Degree of Discipline X Was the act deliberate with a reasonable knowledge of the possible consequences? X Has the person made similar errors in the past? X Do they accept responsibility for their actions? X Has the person learned from the experience? X Are they likely to do it again?

Anyone can make a mistake but only a fool (company or individual) makes the same mistake twice

Degree of Discipline X Was the act deliberate with a reasonable knowledge of the possible consequences? X Has the person made similar errors in the past? X Do they accept responsibility for their actions? X Has the person learned from the experience? X Are they likely to do it again? Remember the reason for Discipline To Ensure It Does Not Happen Again

Discipline – To Ensure That It Does Not Happen Again He was found NOT GUILTY No hull insurance Wife severely injured Pilot severely injured Off work for a month

SAFETY culture 2. 1. TRUSTING culture JUST culture (G. Dupont) James Reason Gordon Dupont

Step 2 A Trusting Culture Levels of Trust Synergistic - WE can solve the problem High (Win Win) Respectful - Compromise Trust Low (Win Lose – Lose Win) Defensive – Us vs. Them (Lose Lose) Cooperation High

SAFETY culture 3. 2. 1. REPORTING culture TRUSTING culture JUST culture (G. Dupont) James Reason Gordon Dupont

Step 3 A Reporting Culture provides the means to capture the lessons to be learned arising from human errors, near misses or free lessons You can’t fix what you don’t know

MEDA (Maintenance Error Decision Aid) Objectives Many Current Error Investigation Processes Event Occurs Investigation Reveals Event Caused by Maintenance Error Determine Who Made Error Administer Discipline The MEDA Process Event Occurs Investigation Reveals Event Caused by Maintenance Error Add to Maintenance Error Data Base Determine Who Made Error Interview Responsible Personnel Find Contributing Factors Get Ideas for Process Improvement Make Process Improvements Based on Contributing Factors Based on This Event Based on Analysis of Data for Multiple Events Follow-up to Obtain Additional Contributing Factors and Information Provide Feedback to All Employees Affected by Process Improvements

Don’t Sweat the Small Stuff And You Will Avoid Having to Sweat the Big Stuff Gordon Dupont This is what SMS is all about The Small Stuff has the potential to become the Big Stuff For Example

SAFETY culture 4. 3. 2. 1. LEARNING culture REPORTING culture TRUSTING culture JUST culture (G. Dupont) James Reason Gordon Dupont

Step 4. A Learning Culture Enables us to take the reports with their “Free lessons” and through Risk Management lower the hazards that threaten the Safety of the organization Enables us to analyze what we weren’t even aware of before We are able to fix the problem (Hazard) before it causes an accident Takes us from the Reactive level to the Proactive level

Step 4 A Learning Culture Where human factors training is provided to all on an ongoing basis Where incident data is kept and analyzed to find trends and develop Safety nets Where major changes are carried out when the present system is not sufficiently Safe Where feedback is provided as a means of learning from all incidents

SAFETY culture 5. 4. 3. 2. 1. INFORMED culture LEARNING culture REPORTING culture TRUSTING culture JUST culture (G. Dupont) James Reason Gordon Dupont

Step 5 An Informed Culture Where everyone knows the organization’s true Safety commitment 1. A Mission Statement - Posted

A Mission Statement That Everyone Knows

Step 5 An Informed Culture Where everyone knows the organization’s true Safety commitment 1. A Mission Statement - Posted 2. A Safety Policy - Posted

Management Managers and supervisors Managers and supervisors Supervisors Supervisory Employee Employee Everyone

This is an excellent one

Step 5 An Informed Culture Where everyone knows the organization’s true Safety commitment 1.A Mission Statement - Posted 2.A Safety Policy - Posted 3. An Administrative Policy – Known by all 4. Long term Safety goals – Known by all who work toward them 5. Optional - Core Values Statement - Posted

SAFETY culture 6. 5. 4. 3. 2. 1. FLEXIBLE culture INFORMED culture LEARNING culture REPORTING culture TRUSTING culture JUST culture (G. Dupont) James Reason Gordon Dupont

Step 6 A Flexible Culture Where necessary changes are order to improve Safety Where the organization is looking for better ways to work Safer made in constantly Where the status quo is not considered an option in the quest to lower errors Where there is a “Chronic Unease” that in spite of all efforts, human error will still occur Where an Emergency Response Plan (ERP) is in place in the event of an error occurring

ha Y ou v cu e n a lt o is ur Sa w A e f LA th et R at y P 5. 4. 3. 2. 1. SAFETY culture 6. FLEXIBLE culture INFORMED culture LEARNING culture REPORTING culture TRUSTING culture JUST culture (G. Dupont) James Reason Gordon Dupont

Thank You for the Opportunity to Provide this Message Gordon Dupont

What Class of Error? Honest, At-Risk, Reckless

How do we measure this?