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Safety Culture Informed, Just and Fair


Safety Culture Informed, Just and Fair Patrick Hudson ICAO/Leiden University Structure How safe is aviation? Safety culture The elements of a safety culture The need ... – PowerPoint PPT presentation

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Title: Safety Culture Informed, Just and Fair

Safety Culture Informed, Just and Fair
  • Patrick Hudson
  • ICAO/Leiden University

  • How safe is aviation?
  • Safety culture
  • The elements of a safety culture
  • The need for a Just Culture
  • Why it is complicated?
  • What if it goes wrong?
  • Conclusion

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How Safe is Aviation?
  • Hull losses are low, we are worrying about the
    effect of increased exposure at current levels of
    flight safety
  • But is the aviation industry safe or is it just
    safe for passengers?

Aviation isnt that safe US data 1997
Lost Workday Incidents per 100 Employees in US
9 8 7 6 5 4 3 2 1 0
Frequency Rate
Courtesy DuPont
It doesnt get better - 2001
Safety Culture The Added Ingredient
  • Safety Management Systems provide a systematic
    approach to safety
  • 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

Safety Culture indicators
chronic unease safety seen as a profit centre new
ideas are welcomed
resources are available to fix things before an
accident management is open but still obsessed
with statistics procedures are owned by the
we cracked it! lots and lots of audits HSE
advisers chasing statistics
we are serious, but why dont they do what
theyre told? endless discussions to re-classify
accidents Safety is high on the agenda after an
the lawyers said it was OK of course we have
accidents, its a dangerous business sack the
idiot who had the accident
The Evolution of Safety Culture
GENERATIVE safety is how we do business round
Increasing Informedness
PROACTIVE we work on the problems that we still
CALCULATIVE we have systems in place to manage
all hazards
REACTIVE Safety is important, we do a lot every
time we have an accident
Increasing Trust Accountability
PATHOLOGICAL who cares as long as were not caught
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Characteristics of a Safety Culture
  • Informed - managers know what is really going on
  • Reporting - the workforce is willing to report
    their own errors and near misses
  • Just - a no blame culture, with a clear line
    between the acceptable and unacceptable
  • Wary - ready for the unexpected
  • Flexible - operates according to need
  • Learning - willing to adapt and implement
    necessary reforms

How to create a Safety Culture
  • Depends on where you are starting from -
    unfortunately you cant get to the end in one go,
    all the steps have to be traversed
  • Becoming a Safety Culture involves
  • acquiring a set of safety management skills
  • and then maintaining them
  • The two major factors are informedness and trust,
    and these have to be developed over time
  • Be systematic (Safety Management Systems are a
    start) and then learn to operate with the unknown
    as well

Developing a Safety Culture Informed and Learning
  • Agree on ways to analyse incidents to reveal both
    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 incidents are worth reporting
  • Practice management in wanting to know from near
    misses before they become accidents

A Reporting Culture
  • In order to get the information we need, we need
    to be told
  • This often requires people to admit their own
    errors - this is personally difficult at best
  • The workforce will not tell what they have done
    if they are afraid of the consequences
  • Pathological and Reactive cultures shoot the
  • Generative organisations train messengers!

Developing a Safety Culture Just
  1. Get rid of the idea that blame is a useful
    concept (this is hard to do)
  2. Define clear lines between the acceptable and the
  3. Have those involved draw up the guidelines, do
    not impose from above if you want them to be
  4. Have clear procedures about what to do with other
    forms of non-compliance

Why is Blame so easy?
Human Error - The Problem
  • If an accident happens people want to blame
  • Insurance - who pays?
  • Criminal responsibility - who goes to prison?
  • Technical failures are usually seen as less
  • This often applies even with near misses

  • Blame is something that is attached to
  • What about objects?
  • What about non-human entities?
  • Blame is associated with causality
  • People attribute cause to other people
  • Bad people have bad accidents

  • Fundamental Attribution Error
  • Individuals attribute causes of their own actions
    to external causes
  • They attribute causes of the actions of others to
    personal factors in those individuals
  • There is a belief that The World is Just
  • This leads to the idea of accident proneness
  • Bad things happen to bad people
  • Also called Outcome bias

Hindsight Bias
  • Hindsight Bias (Fischhoff, 1975)
  • One knew it all along
  • Known branches are over-estimated
  • We now know the outcome, we didnt before
  • The scenario now seems easy to generate and
    therefore was easy before the event
  • In advance, bad outcomes are evaluated as less
    likely, especially if you feel you can control
  • If you knew the best options, and could have
    controlled for them, then selecting any other
    must be incompetent!

The Illusion of Free will
  • People believe they have free will
  • They can always choose what they will do
  • They can foresee the consequences of their
    actions and act accordingly
  • They attribute this to others
  • They commit the fundamental attribution error
  • Hindsight bias makes the choices seem less and
    more obvious than at the time
  • They regard human failures as more avoidable than
    technical failures

The Law - Prosecution
  • Prosecutors are tasked with finding one or more
    individuals to prosecute
  • Prosecutors will only proceed if there is a
    reasonable chance of success
  • The closer to the event the harder the evidence
  • The further from the event, the more doubt can be
    introduced about alternative causes
  • Any amount of specific evidence may be sufficient
    in a criminal case

Corporate Manslaughter
  • Targeting company bosses is the new approach
  • Based on a duty of care concept - bosses have a
    duty to ensure safety
  • Lord Denning defined the Guiding Mind principle
  • This has proved hard to obtain prosecutions
  • The principle of Executive Authority makes it
    easier to prosecute (When the executive says
    jump, subordinates ask how high, not vice-versa)

Who is convinced?
  • Prosecutors
  • Police
  • Investigators
  • Judges
  • Juries (in jury systems)
  • Colleagues
  • The accused themselves

Thinking about a Just Culture
  • The need to have rules and procedures
  • The standard approach to non-compliance
  • Marx and Reasons Just Culture
  • A new approach - Hearts and Minds
  • Types of violation - Managing Rule Breaking
  • Roles of those involved - Managers to Workers
  • Individuals - the reasons for non-compliance
  • Solutions - from praise to punishment
  • From Just Culture to Fair Culture

The need for rules
  • Many hazards cannot be controlled by hardware or
  • Other hazards are more easily controlled by
    administrative approaches
  • There are three levels of specification
  • Guidelines
  • Descriptions and sequences
  • Work instructions
  • Failure to follow procedures temporarily negates
    the control of the management system
  • The assumption is that all the rules will be

The Simple View - How to manage non-compliance
  • Rules and procedures are there for a purpose
  • Personnel are expected to know them and are
    clearly expected to comply with all relevant
  • Failures to comply represent a deliberate failure
    of an individuals performance contract
  • Such failures cannot be tolerated, because the
    HSE-MS relies upon compliance
  • Non-compliance is best managed by making people
    aware of the personal consequences, from written
    warnings to dismissal

Review of the Simple View
  • There is an assumption that all rules and
    procedures are optimal and not in need of
  • The US Nuclear INPO studies found that 60 of
    procedural problems were due to incorrect
  • The requirement is for unquestioning compliance
    by a worker
  • The INPO studies found that most people did
    follow procedures, even when they were incorrect
  • A weaker version of such requirements may require
  • This is often based upon following the incorrect
    rule or procedure first, with subsequent challenge

The Just Culture - Version 1
  • Originated by David Marx - a Boeing engineer and
    also a lawyer
  • Propagated by Prof James Reason
  • Starts with assumption of deliberate violation
    (e.g. sabotage) by individuals (Marx found about
  • Next employs the substitution test (would others
    have done the same?) to check for individual vs
    system blame
  • If there is no evidence that an individual was
    reckless and there is no history of previous
    non-compliance, then define non-compliance as

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Review of Just Culture v.1
  • The model appears to assume individual guilt
    unless proven otherwise
  • The drawing, going from left to right, implies
    visually where priorities lie. The amount of
    space devoted to discipline does the same
  • There are only two points where management is
    required to remedy system problems identified,
    after the event. Most are concerned with
    distinguishing whether a worker should have more
    discipline or just be actively coached until they

The Just Culture - Version 2
  • Empirical studies of non-compliance showed a
    complex picture
  • 6 different types of violation
  • Managers and supervisors have a role as well as
    the violating worker
  • Individuals will be working with a variety of
    intentions, from the companys interest to their
    personal gain
  • Solutions range from improving the system to
    ensuring compliance

Example DAL 39
  • An example of what happens today in Western
  • Criminal prosecution of three air traffic
  • All 3 found guilty of a misdemeanor at Court of
  • No punishment because of the system failures, but
    no prosecution of management

DAL 39
  • A Delta 767 aborted take-off at Amsterdam
    Schiphol on discovering a 747 being towed across
    the runway
  • Reduced visibility conditions (Phase - B)
  • The tower controller was in training, under the
    tower supervisor
  • There was another trainee and of the 11 people in
    the tower five were changing out to rest
  • The incident happened between the inbound and
    outbound morning peaks

Runway Incursion (1998)
The DAL 39 event scenario
Tunnel brought into use without briefings
Pilots see 747 and abort take-off
Routine violation of tow procedures
Airport decides to change airport structure
Tower combining training and operations during
difficult periods
Controller gives clearance without assurance of
tow position
Why did all this happen - 1?
  • Tow was in violation, but this appears to be
  • No clear protocols for ground vehicles and no
    hazard analysis
  • Different language for aircraft (English) and
    ground vehicles (Dutch)
  • Poor quality of ground radio
  • Clearances appeared to be unlimited once given
  • Tower supervisor was also OTJ trainer in the
    middle of the rush hour
  • Altered control box not introduced to ATC staff

Why did all this happen - 2?
  • No briefings about alterations at Schiphol (It
    has been a building site for years)
  • Too many trainees in the tower in rush hour under
    low visibility conditions
  • Differences in definition of low visibility
    between aerodrome and ATC
  • No management apparent of the change in use of
    the S-Apron
  • No operational audits by LVNL or Schiphol, of
    practice as opposed to paper
  • Schiphol designed requiring crossing and the use
    of multiple runways for noise abatement reasons

Could this have been known in advance?
  • Many problems are known in advance
  • If no one tells they will certainly happen again
  • If people fear prosecution and other consequences
    of admitting their errors, will they tell?
  • Without reporting, we are doomed to wait until we
    have an accident that everyone can see

Learning from Errors requires Trust
International oversight
Safety improvements
Lessons learned
National Legislation
Incident Reports
What happens when prosecution takes place?
  • After the DAL-39 case, ATCOs reduced the number
    of reports about ATC errors
  • They continued to report pilot errors
  • They were no longer being prosecuted

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What next?
  • It became clear that a new approach was needed
  • The old model was even found to be the cause of a
    major accident!
  • All types of errors and violations need to be
  • Positive reporting should be rewarded
  • There are still actions that everyone agrees are
    unacceptable (Reckless, personal)

Shells new model
  • Shell decided that the concept of the Just
    Culture needed to be extended
  • To cover rewards for good behaviours
  • To reflect the differences in types of violations
    and errors
  • To highlight the responsibilities of both
    individuals who break the rules and their
    managers who condone or do not want to know

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Decision Flowchart
  • All actions now have consequences
  • These apply both to the individual and their
  • Distinguishing different types of violation is
  • Everyone has to agree to the process and the

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  • Safety cultures make the difference between a
    mechanical application of SMS and full
    implementation that obtains the maximum benefits
  • A Just and Fair Culture is essential for
  • Without reporting no one knows what is going on,
    until it is too late