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Transcript of 1 Safety Culture Process Barry KIRWAN - EUROCONTROL [email protected] European...
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Safety Culture Process
Barry KIRWAN - EUROCONTROL [email protected]
European Organisation for the Safety of Air Navigation
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Real Safety Culture, real safety issues.
A controller makes a mistake, but no A controller makes a mistake, but no one sees it. Does he report it?one sees it. Does he report it?
A supervisor sees ‘cowboy’ A supervisor sees ‘cowboy’ behaviour by a controller, but the behaviour by a controller, but the supervisor is no longer connected supervisor is no longer connected with the teams. Does he act?with the teams. Does he act?
Two Department Heads (Ops & Eng) Two Department Heads (Ops & Eng) know their departments don’t work know their departments don’t work well together. Do they ignore it?well together. Do they ignore it?
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The Safety Culture Process
Preparation Meeting (Oct)Preparation Meeting (Oct) Launch (Jan)Launch (Jan) Questionnaire (Jan)Questionnaire (Jan) First Diagnosis (March)First Diagnosis (March) Workshops (April)Workshops (April) Analysis & RecommendationsAnalysis & Recommendations Presentation to Management Presentation to Management
(May)(May) Report (June)Report (June) Presentation to Staff (June)Presentation to Staff (June) Action Plan (Sept)Action Plan (Sept) 0%
20%40%
60%80%
100%
My management is committed to safety(G7)
My colleagues are committed to safety(G4)
The organisation tries to do more than just meet the minimum safety regulations(G9)
4%
7%
6%
14%
4%
17%
81%
89%
78%
HOW STRONG IS THE COMMITMENT TO SAFETY?
Unfavourable Neutral Favourable
Results of a Safety Culture Survey at
XXXXXVersion: 1.0
Date: 3 June 2011
Confidential
0%20%
40%60%
80%100%
Changes to the organisation and ATC system do not increase safety-related risks(M18)
I am concerned that an operational incident will happen in the near future(C3*)
I am concerned that equipment, important to operational safety (e.g. radar) will fail in the near
future(E12*)
11%
25%
63%
33%
23%
19%
56%
52%
19%
COULD YOUR ANSP BE INVOLVED IN A SERIOUS SAFETY INCIDENT?
Unfavourable Neutral Favourable
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The Process – High Level
Decide to embark on the Safety Culture ProcessDecide to embark on the Safety Culture Process Elect a champion, back the championElect a champion, back the champion Engage internal stakeholdersEngage internal stakeholders Launch the ProcessLaunch the Process Ensure good participationEnsure good participation Expect a mixture of newsExpect a mixture of news
• Strengths• Areas for improvement
Give feedback to participantsGive feedback to participants Build on the ResultsBuild on the Results
Prepare
Launch
Run
Learn
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Step 1. Prepare (1/2)
Consider Benefits & CostsConsider Benefits & Costs• Better risk picture & management; Staff engagement in
safety vision• Costs of staff involvement (time); External supply costs
Consider Breadth & TimingConsider Breadth & Timing• Participation: ATCOs, Engineers, Managers, All?• Locations: HQ, ACCs, Towers, other?• Other initiatives? Ongoing problems/issues?
Elect Champion & Support ChampionElect Champion & Support Champion• Trusted by both staff & management; visible
management commitment (CEO/Board announcement); Inform Internal StakeholdersInform Internal Stakeholders
• Heads of Departments; Staff Committees; Unions; etc.
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Step 1. Prepare (2/2)
Select ApproachSelect Approach• Questionnaire; focus groups
Select TechniqueSelect Technique• Off-the-shelf; Bespoke• Eurocontrol; Keil Centre; other
Select Outside AgencySelect Outside Agency• Eurocontrol; Consultancy; University
Determine Launch DateDetermine Launch Date• Best if not during summer period
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Step 2. Launch
Management BriefingManagement Briefing All Staff BriefingAll Staff Briefing Multi-CentreMulti-Centre Explain Explain Why, What, So WhatWhy, What, So What Stress independence/anonymityStress independence/anonymity Practical Points (POCs; Timings)Practical Points (POCs; Timings) Survey team familiarisation and Survey team familiarisation and
observation, walk-rounds, etc.observation, walk-rounds, etc.
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Questionnaire Analysis
Identify Key Issues
Analysing the Issues
Prioritising the Issues
Solution proposals
Understandingthe Issues
Feedback to Management & Staff
Workshops
After the workshops
Survey the population1. General section2. Controllers/Assistants3. Maintenance/Engineering4. Managers
Improvement Strategy
Step 3: Running the Survey - The Heart of the Process
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SAFETY CULTURE
Commitment
Teaming
Learning &Reporting
Responsibility
Involvement
Communications& Trust
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Questionnaires
Below is a list of statements regarding safety issues that are relevant to your role in the organisation. Please indicate the extent to which you agree/disagree with each one by circling one number on each line. We want your opinion about how your organisation currently works.
Str
on
gly
dis
ag
ree
Dis
ag
ree
Ne
ith
er
Ag
ree
Str
on
gly
ag
ree
Comment
1. Even if some equipment is unavailable, we are still required to meet our capacity targets
1 2 3 4 5
2. The equipment that is available is suitable for my job 1 2 3 4 5
3. In ATC everyone knows there is an accident ‘just waiting to happen’
1 2 3 4 5
4. Maintenance staff understand how equipment failures affect our ability to provide safe air traffic services
1 2 3 4 5
5. I trust the ATC procedures that I use in my job 1 2 3 4 5
6. Maintenance staff perform sufficient system checks 1 2 3 4 5
7. The future plans are adequate for the development of the ATC service
1 2 3 4 5
8. I trust the ATC equipment that I use in my job 1 2 3 4 5
9. We openly discuss incidents in an attempt to learn from them
1 2 3 4 5
10. Controllers would never compromise their responsibility for safety
1 2 3 4 5
11. We are expected to be able to handle safety problems without reducing throughput
1 2 3 4 5
12. We are consulted about changes to the technical/ engineering system that impacts on the way we do our work
1 2 3 4 5
13. There is pressure to use smaller safety margins than I feel comfortable with
1 2 3 4 5
14. It is possible for operational and technical/ engineering systems teams to meet together and discuss potential solutions for past problems
1 2 3 4 5
Controllers
Engineers
Managers
General
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Sample Results: Best 5 items
1
1,3
3,6
3,6
3,3
2,3
2
2,3
3,6
3,9
96,8
96,7
94,1
92,9
92,8
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Only my manager hasresponsibility for safety
Only the Safety Departmenthas responsibility for safety
Each member of staff hasa responsibility to keep up
with changes toprocedures
If I do something wrong, Ican discuss it with my
colleagues withoutworrying about the
consequences
I have confidence in thepeople that I interact with in
my normal workingsituation
% of respondents
% unfavourable
% neutral
% favourable
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Sample Results: Bottom 5 items
38,5
35,5
46,4
53
60,3
20,9
26,1
17,9
15,2
12,2
40,5
38,3
35,8
31,8
27,5
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
We have sufficient safetyexperts and support staff in
house
There is a lack of feedback onthe results of safety initiativesthat we have participated in
The other people in theorganization do not understandour job and the safety roles we
fulfil
Feedback from incidentscomes months or years laterwith few recommendations
Even if the system fails, we arestill expected to achieve thetargets that are set for us
% of respondents
% unfavourable % neutral % favourable
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Focus Group Process
4-6 GROUPS (mixed) + 4-6 GROUPS (mixed) + FacilitatorsFacilitators
Key issuesKey issues• Ensure understanding• Consider causes and
consequences
Potential solution pathsPotential solution paths Key ways forwardKey ways forward Mode: Facilitated ProcessMode: Facilitated Process
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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
Project Coordination:Sílvia Agostinho da Silva
CIS/DEPSO/ISCTE/[email protected]
Output: Confidential Report to ANSP
1. ‘Diagnosis’ of ANSP Safety Culture2. Detailed Results by Group & Region3. Suggested Ways Forward:
Quick wins & longer term solutions
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ANSP Safety Culture Enhancement Strategy
Decide the options and the prioritiesDecide the options and the priorities• Strategic – e.g. safety culture campaigns• Tactical – e.g. improve computerised incident
reporting system
Allocate responsibilities & resourcesAllocate responsibilities & resources Be realistic about the time it can take to Be realistic about the time it can take to
change culturechange culture Track & Monitor ProgressTrack & Monitor Progress Communicate, communicate, communicateCommunicate, communicate, communicate
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Timescale of the Survey Process
00 1m1m 3m3m 6m6m 1yr 1yr 3 years3 years
LaunchLaunch
AnalysisAnalysis
Focus Focus groupsgroups
ImprovementImprovementStrategyStrategy
Mid-termMid-termReviewReview
Strategic reviewStrategic review22ndnd Measurement Measurement
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1. Positive safety culture2. ‘Passion for safety’ 3. High Risk Awareness4. Involvement in Safety
5. Pace of change6. Communications7. Learning from incidents8. Trust between Teams
SAFETY CULTURE
ELEMENTS
RiskAwareness
Teamwork
Communications
Involvement
Commitment &
Responsibility
Learning and Trust
Example ‘Board Level’ Picture
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Example Recommendations
Supervisor is a key asset – re-Supervisor is a key asset – re-assess safety function of assess safety function of supervisor, especially how to supervisor, especially how to support safety culture in the shift support safety culture in the shift ‘teams’‘teams’
Enhance the speed and Enhance the speed and transparency in incident feedback transparency in incident feedback to controllers – and extend the to controllers – and extend the process to maintenance process to maintenance engineersengineers
Deal with certain safety ‘hotspots’ Deal with certain safety ‘hotspots’ identified in the surveyidentified in the survey
Review OJTI training protocols in Review OJTI training protocols in high intensity work situationshigh intensity work situations
Determine top ten ‘hit-list’ of safety Determine top ten ‘hit-list’ of safety issues for the organisationissues for the organisation
Evaluate extent of ‘workarounds’Evaluate extent of ‘workarounds’ Gain more operational involvement Gain more operational involvement
in HAZOPs etc.in HAZOPs etc. Clarify safety responsibilities for all Clarify safety responsibilities for all
staff including corporate staff including corporate managementmanagement
Prioritise safety resourcesPrioritise safety resources Renew Team Resource Renew Team Resource
ManagementManagement
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Support
Getting StartedGetting Started• White Paper; ‘Brochure’; Safety Culture
Toolbox Technical SupportTechnical Support
• EUROCONTROL Safety Team; CANSO; FAA • Consultancies (e.g. the Keil Centre in the UK;
NLR in Holland);• Universities (various, e.g. Aberdeen [UK],
Lund [Sweden]; Leiden [Holland] etc.) Continued SupportContinued Support
• EUROCONTROL, CANSO and FAA all have placed Safety Culture as a strategic objective over the next 5 years.
Peer SupportPeer Support• EUROCONTROL planning ANSP regional
workshops in 2009 onwards
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Summary
The measurement of safety culture is relatively matureThe measurement of safety culture is relatively mature There is an agreed process: although some individual There is an agreed process: although some individual
tools may differ, they deliver similar resultstools may differ, they deliver similar results It is not a painful processIt is not a painful process There is support availableThere is support available More and more European Member States signing upMore and more European Member States signing up
Questions?
SafetySafety
CostsCosts