The European Organisation for the Safety of Air Navigation

Safety Culture: Can we improve it?

Barry Kirwan

EUROCONTROL

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

The European Organisation for the Safety of Air Navigation

Safety Culture Progress in AVINOR Chief executive ANS Knut Skaar

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.

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.

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.

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InformedCulture

Just Culture

ReportingCulture

Learning Culture

FlexibleCulture

‘Pillars’ of Safety Culture (James Reason)

Safety Culture in European ATM 8

InformedCulture

Just Culture

ReportingCulture

Learning Culture

FlexibleCulture

AVINOR Approach, Post-Survey

Dialogue,Involving allPersonnel

ImprovedInformation

Flow

Building Building CompetenceCompetence

UnderstandingRegional

Differences

Better Risk PictureRe-assessing Priorities

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Safety Culture Campaign – ANS Roadshow

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?

The European Organisation for the Safety of Air Navigation

How much can we change in 2 -3 years?

Safety Culture in European ATM 12

Safety Culture – Second time aroundKjersti Disen

Avinor

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

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Improvement Areas

• Exercising priorities• Improving feedback after reporting• Team-meeting places• Improve management of change• Relation to regulator.

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Second Safety Assessment – 2009 Number of responses

310

482

0

100

200

300

400

500

600

2007 2009

Number of responses

82

117

2349

129

3547

En-route controllers Approach controllers Tower controllers

Assistant controllers Engineers Managers

Other

Safety Culture in European ATM 16

Reporting & Learning

Increases in favourable responses scores for items included in both the 2007 and 2009 survey

53,168

4672

65,380,3

0 10 20 30 40 50 60 70 80 90

Lessons learned from incidents are published in a de-identif iedmanner in a new sletter or similar document (G29)

People in this organization share information in order to keepthe organization w orking properly (G19)

People understand the need to report incidents in order toidentify trends and make changes to the system if required

(G24)

2007 2009

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Communication

Increases in favourable responses scores for items included in both the 2007 and 2009 survey

Safety Culture in European ATM 18

Second Safety Assessment – 2009

0

10

20

30Responsibility

Commitment

Communication

TrustReporting & Learning

Teamwork

Involvement

2007 2009

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.

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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.

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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.

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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!”

The European Organisation for the Safety of Air Navigation

Can other ANSPs repeat this progress?

The European Organisation for the Safety of Air Navigation

Meeting with Users

Safety Culture at Safety Culture at NAV PORTUGALNAV PORTUGAL

Safety Culture in European ATM 25

MadridMadridMadridMadrid

CasablancaCasablancaCasablancaCasablanca

CanáriasCanáriasCanáriasCanárias

ShanwickShanwickShanwickShanwickGanderGanderGanderGander

New YorkNew YorkNew YorkNew York

PiarcoPiarcoPiarcoPiarco SalSalSalSal

SANTA MARIA SANTA MARIA

OCEANIC FIROCEANIC FIR

SANTA MARIA SANTA MARIA

OCEANIC FIROCEANIC FIR

LISBO

N FIR

LISBO

N FIR

LISBO

N FIR

LISBO

N FIR

BrestBrestBrestBrest

Airspace controlled by NAV Portugal, and adjacent FIR’s

Safety Culture in European ATM 26

Safety ManagementSafety ManagementSafety ManagementSafety Management

Safety Management

Safety Safety PolicyPolicyand and

PrinciplesPrinciples

Safety Safety PolicyPolicyand and

PrinciplesPrinciples

SafetySafetyAssessmentAssessmentMethodologyMethodology

SafetySafetyAssessmentAssessmentMethodologyMethodology

SafetySafetyManagementManagement

ToolsTools

SafetySafetyManagementManagement

ToolsTools

SafetySafetyCOMMUNICATIONCOMMUNICATION

and and TrainingTraining

SafetySafetyCOMMUNICATIONCOMMUNICATION

and and TrainingTraining

•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 SURVEYSSAFETY CULTURE SURVEYS

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NAV Portugal SMSNAV Portugal SMS

Guidelines for the Safety Culture’s evaluation .

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Results of a Safety Culture Survey at NAV PORTUGAL

Version: 3.0Date: 30 April 2007

Safety culture : qualitative and quantitative assessment

A Tale of Two Surveys (2007)

Project Coordination:Sílvia Agostinho da Silva

CIS/DEPSO/ISCTE/PORTUGALsilvia.silva@iscte.pt

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NAV-P Strong points

1. High concern with safety2. Participants’ declared values in line with the

company's safety policy3. 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                              

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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

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Reducing NAV-P’s Negative Safety Culture ‘Footprint’

0,00

5,00

10,00

15,00

20,00

25,00

30,00

35,00

40,00COMMITMENT

COMMUNICATION

INVOLVEMENT

REPORTING & LEARNINGRESPONSIBILITY

TEAMWORK

TRUST

2007

2009

The European Organisation for the Safety of Air Navigation

Regional Workshops

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Regional Workshop - 14/15 December Paris

Who Attended• ROMATSA

• NATS

• BELGOCONTORL

• AVINOR

• ENAV

• SLOVENIA CONTROL

• IAA

• NAV-P

• ARMATS

• MUAC

• EUROCONTROL

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Regional Workshop - Knowledge Sharing

Agenda• ANSP Presentations

• 6 ANSPs shared safety information

• Workshops

• Learning from incidents

• The role of the Supervisor

• Just Culture

• Communication

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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

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Regional Workshop - Deliverables

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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.