Safety Management Systems

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Safety Management Systems

• The Natural Successor to Error Management Systems
• (from the Asian Culture Perspective)
• Presented to Asia Pacific Airline Training
  Symposium 2008
• Kenny So, Senior Airworthiness Officer,
• Civil Aviation Department, Hong Kong, China
• Date 16 September 2008

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Can we have Safety Management without Error
Management?

• YES but
• It is a much harder objective to reach if you are
  starting Safety Management Systems (SMS) from
  scratch.
• Maybe a better start point would be Human Factors
  training.
• Why?
• Because Human Factors introduces us to the
  concept of Error Management.

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Error Management What is that?

• It is a concept which accepts that errors will
  always occur at some point in any system which
  involves a Human-Machine interface.
• A famous Greek philosopher coined the phrase
  Errare humanum est
• To err is human (err make a mistake)

4
OK, but what is the difference between Error
Management and Safety Management?

• The difference is reactive as opposed to
  proactive.
• Reactive looks at events which have already
  happened, Proactive seeks to anticipate events
  which might happen and put in place defences
  against that event or mitigation strategies to
  minimize the effects of the event if it did
  happen.

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Why did slide 1 include the phrase, the Asian
Cultures perspective?

• Because it is very important that aviation safety
  practitioners (particular non-native) recognize
  the importance of CULTURE when seeking either to
  educate people about, or implementing concepts
  such as, Human Factors, Error Management and SMS.
• What works in London/New York/Sydney will not
  necessarily work in Hong Kong/China.

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Why not?

• Because the people cultures are different.
• European cultures tend to be individualistic
  where personal achievement and recognition are
  highly regarded and where mistakes are accepted
  as an integral part of the learning process.
• Asian cultures tend to be more collectivist
  where people prefer not to stand out from the
  crowd either in a good or bad sense.

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So what effect does this have on the
implementation of SMS?

• There is no perfect culture with regard to
  Safety!
• Let us first take a look at some of the basic
  cultural considerations here we will consider
  organisational culture.
• For our SMS to be effective, the organisational
  culture must be.

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An Informed Culture

• People understand the hazards and risks involved
  in their operations.
• Staff work continuously to identify and overcome
  threats to safety.

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A Just Culture

• Errors must be understood, but willful violations
  cannot be tolerated.
• The workforce knows and agrees on what is
  acceptable and unacceptable.

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A Reporting Culture

• People are encouraged to report safety concerns.
• When safety concerns are reported, they are
  analyzed and appropriate action is taken.

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A Learning Culture

• Staff are updated regularly on safety issues by
  management.
• Safety information is fed back to staff so that
  everyone learns the lesson.
• People are encouraged to develop and apply their
  own skills and knowledge to enhance
  organisational safety.

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Idealistic Perhaps!?!

• What about the realities?
• What about the peoples culture and behaviour?
• What about social norms?

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Cultural Obstacles Social Patterns

• Some typically observed comments
• I wont report any safety issues because Ill be
  seen as a troublemaker.
• I wont report mistakes that I make because that
  will mean a loss of face for me.
• If I see safety issues involving colleagues I
  wont report these because that would mean a
  loss of face for them and our GuanXi
  friendship will be ruined.

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Cultural Obstacles Social Patterns

• More typically observed comments
• I dont have anything of value to add to the
  enhancement of organisational safety Im only
  a small potato.
• I cannot challenge what my boss wants me to do
  even if I think there are safety issues involved
  his post is higher and therefore his decisions
  must be respected.

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Cultural Obstacles Social Patterns

• Some typically observed behaviours
• Deliberate covering up of mistakes by oneself and
  others.
• Denial Refusal to accept responsibility for
  errors even in the face of damning evidence.
• Belief that sorry sorry when found out will
  make everything alright but having no thoughts
  as to how or why the error occurred.

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Not true?

• Of course not, within our organisation those
  sorts of behaviour would not be tolerated
• DENIAL.!

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Social Norms

• Lets have a look at some social norms
• The love affair with the mobile phone.
• The love affair with the I-Pod.
• A perceived lack of situational awareness.
• A perceived lack of concern for personal safety,
  either ones own or that of others.

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Social Norms

• Even though we do not necessarily realize it,
  these norms have a direct impact on how we go
  about our business and on the job we do.
• They need to be recognized and personal
  strategies implemented to minimize the risks
  associated with them.

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Too Simplistic and BIASSED!?!

• Yes and No!!!
• Yes, there is bias, interpretation of other
  peoples behaviour based on ones own cultural
  background, however
• The comments and behaviour described are factual.

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BEHAVIOUR

• People who work in aviation do not normally
  exhibit deviousness or deviant behaviour.
• So how do we explain the behaviours outlined
  earlier?

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CONFUCIUS

• I have to turn to Confucius for an answer to this
  question.
• Confucius "Master Kung," (551 BC
• 479 BC) was a Chinese thinker and
• social philosopher, whose teachings
• and philosophy have deeply influenced
• Chinese, Korean, Japanese, and Vietnamese
  thought and life. His philosophy emphasized
  personal and governmental morality, correctness
  of social relationships, justice and sincerity.

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CONFUCIUS

• Chinese culture and Confucian teaching emphasize
  the group or family over the individual.
  Confucianism also stresses obedience to
  elders/leaders as well as a need for harmony
  (either within the family or workplace). In fact
  the workplace can and does take on the identity
  of the Big Family.

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CONFUCIUS

• Not necessarily directly attributable to
  Confucius, but another feature of the
  collectivist culture which manifests itself
  both in Hong Kong and China, is the concept of
  collective responsibility/accountability.
• When an incident or accident occurs, great effort
  is expended in the dilution of individual
  responsibility (spreading the blame) such that
  root cause, which may be individually rather than
  organisationally related, becomes almost
  impossible to identify thereby denying the
  opportunity for implementation of appropriate
  mitigating strategies.

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LEADERSHIP

• Accepting the principle of familial loyalty,
  a need to maintain a harmonious working
  environment, and Confucian traditions of
  hierarchical management style, it is my belief
  that for the successful implementation of an SMS
  in a Chinese context, indoctrination of top
  management from the outset is critical. Without
  this, in a traditional setting, the message
  will not reach the workforce.

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ENGAGEMENT

• ?With top management on-side, engaging staff in
  the System Improvement Process is the next
  crucial element.
• ?Engagement-Definition Staff connected to their
  work in various ways - intellectually,
  emotionally, creatively and psychologically.

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ENGAGEMENT

• Intellectual Connection Staff are aware of
  safety efforts in progress. They understand why
  we do things the way we do. We want their ideas,
  and we want them to think about what is going on
  in our organisation. We want them intellectually
  connected to organisational safety performance.
• Emotional Connection We want our staff to
  realise that what they think does matter. We
  want them to know that their contribution does
  make a difference.

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ENGAGEMENT

• Creative Connection We want their ideas, their
  suggestions, and their innovations. We want their
  creativity with respect to the work they are
  doing.
• Psychological Connection We want our staff to
  feel that This is an organisation that cares
  about me it cares about me enough to improve the
  overall safety situation, and Im part of that.

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What else?

• Maintenance staff need the support and
  encouragement to do the job right.
• What do we mean by the job?
• Producing a safe (airworthy) aircraft.
• We need to acknowledge their work, which is often
  hidden by access panels, and encourage them to
  take pride in doing the job correctly. Only this
  way we can produce an aircraft that is maintained
  to the highest level of airworthiness.

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How do we achieve this?

• We ensure that maintenance staff are trained and
  competent to perform the tasks which they are
  assigned.
• We provide clear unambiguous guidelines on what
  we expect from our staff.
• We put in place procedures which are easily
  understood.
• We create a just culture where errors are
  understood but where everyone understands that
  deliberate deviation from procedures will not be
  tolerated.
• We provide a safe working environment and
  encourage staff to highlight aspects of the
  working environment that they consider have a
  negative effect on safety, (either personal or
  with respect to the aircraft).

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How do we achieve this?

• We provide clear work instructions and procedures
  are available and must be complied with.
• We provide a clean, uncluttered work environment
  and expect our staff to maintain it this way.
• We ensure that all task specific tooling is
  available as and when required.
• We provide and ensure that all maintenance data
  referenced in the work instructions is current
  (including SBs and ADs.)

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What else?

• We create an environment where open reporting of
  safety related issues is part of the fabric of
  our organisation, because without it we cannot
  hope to reduce risk to as low as reasonably
  practicable (ALARP).
• We cannot do much more Attitude, Confidence and
  Discipline are personal attributes and the
  organisation has a responsibility to impress the
  imperatives of each of these on every member of
  the workforce.

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Conclusions

• To make the quantum leap from todays reactive
  safety environment to tomorrows proactive safety
  environment, the Big Potatoes need to be at the
  vanguard of the organisations Cultural
  Revolution demonstrating in the most visible way
  their commitment to the ideals espoused in the
  Safety Management requirements.

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Conclusions

• Utilising an SMS to manage safety can be the tool
  that bridges the differences to the safety
  performance in regard to the Asian Culture. It
  can move from a position of believing it is
  safe to one of knowing that safety is managed
  and as low as reasonably practicable.

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Thank You !

• Any Questions?