Building a Just Culture for Safety Performance - Can it ... · Just Culture – why? A proactive...

Building a Just Culture for Safety

Performance

- Can it work across national cultures?

Keven Baines – Director

25th March 2015

CHC Safety & Quality Summit

© 2015 Baines Simmons Limited

Workshop flow

2

3. How to build one?

4. Does it deliver/work across national cultures?

2. What is it?

1. Just Culture – why?

Just Culture for safety performance


Just Culture – why?

A proactive safety culture that is founded upon a Just Culture

Being Just is the bedrock of safety performance

Encourages openness and proactive reporting of hazards

Enables you to discover what people have to do to get the job

done

Facilitates risk-based decision-making

3 Just Culture for safety performance


How did Just Culture evolve?

Blame and Train

Culture

No Blame Culture

Just Culture

Just Culture for safety performance 4


Just Culture the key Safety Performance enabler

A Proactive Culture is the

bedrock of safety performance.

A Proactive Safety Culture

encompasses an organisation’s

commonly held perceptions and

beliefs regarding safety and has the

potential to significantly influence

people’s behaviour.

A Proactive Safety Culture is

founded upon a Just Culture in

which individuals freely and openly

share safety-related information in

an atmosphere of trust, born from

a sense of justice.



What are the benefits of Just Culture?

Information

Risks

Improved (risk-based) decision-making

Just Culture

Reporting

Confidence in being treated fairly and feeling

able to change something



Regulatory context

New European regulation on mandatory occurrence

reporting

(No.376/2104) in force from November 2015

“Each organisation established in a Member State shall

.. adopt internal rules describing how ‘just culture’ principles ... are

guaranteed and implemented within that organisation.”



Definition of Just Culture

A culture that recognises that competent

professionals make errors and acknowledges

that even competent professionals will develop

unhealthy norms (shortcuts, routine rule

violations), but has zero tolerance for reckless

behaviour



0%

100%

Human

Reliability

Performance Influencing Factors (PIFs)

The Human Reliability Curve

Human

Error

Normal

Operation

The ‘Error Zone’

It’s part of the human condition to err



Types of error

Because I didn’t quite do what I wanted to do: error (slip)

Because I forgot or wasn’t concentrating: error (lapse)

Because I made the ‘wrong’ decision or plan: mistake



Why are rules intentionally broken?

Because there is no other choice to get the job done:

situational violation

Because this situation has never been imagined: exceptional

violation

Because it’s what we do here: violation for organisational gain

Cant, don't, won’t



Error or violation?



Error or violation?

39 times...



Error or violation?



Do YOU role model it?

Can YOU find it? Can YOU explain it?

Do YOU follow the

process?

“Thanks, but we already have a Just Culture”

Just

Culture

Defined

Understood

Applied Demonstrated



Just Culture Self assessment

16

Client’s average score 43%



It can be measured?

17



Company 1 - safety culture diagnostic



Company 2 - safety culture diagnostic



The safety performance indicators for Just culture



Workshop flow

21



2. What is it?




Just Culture – How?

Understand Build Power-up Perform

Just culture assessment

Safety culture diagnostic

Where are we

now?

What do

we need

to put in

place?

Safety vision

Policies

Procedures

Investigation process

Just Culture toolkit

How do

we

energise

our

staff?

Competence devt

Coaching

Promotion

Education

How do we

sustain our

culture? How

do we know it

is working?

Assurance

Metrics

Balanced scorecard

Safety culture diagnostic...



Just Culture Vision

By the end of 2016 we will have:

...opened up the culture through a high degree of trust between staff and all levels of

management

...everyone able to describe our Just Culture and it will positively shape their decision

making

...become increasingly (20% year on year) less occurrence and more hazard centric

...become increasingly 3rd age so that we know what our people have to do to get the

job done

...a culture were unjustified risk taking behaviour will not be tolerated at any level

...everyone with a genuine ability to say “stop” and be supported by us

...with no exception (irrespective of outcome severity) our Just Culture process will

always be applied.



Error Management System

Threats

and or CFs

Reactive

Unsafe Act (Error/Mistake/Violation)

Event (Unwanted Harm)

Occurrence Reporting

Feedback & Promotion to Develop a

Learning Safety Culture

Hazard/Near-Miss/Error/Mistake/Violation Reporting

Pro Active

Data Exploitation to make human-in-the-

system risk based decisions

Interventions

Investigations

Just Culture toolkit - inc. Event Review Group

and or PIFs

Hazards



FAiR® - what is it..?

a ‘behaviour-based system for creating and sustaining a Just Culture’

… to enable an organisation to ensure that interventions consider the

‘Human In The System’ (HITS)

...treating all in a fair and importantly - a consistent manner

Identify effective interventions

Ensure personal accountability is balanced with the desire for learning and

improvement

Focus on actions and intentions rather than consequences

Cross cultural commonality



Event Review Group responsibilities

27

To ensure a Human Factors-centric investigation and report is complete

identifying the root cause

contributing factors

Ensuring all the ‘Why did it happen?’ questions have been answered

To ensure effective interventions are put in place following an event

To determine any potential accountability.



Typical Event Review Group composition

SMS Manager

Trained ERG members (an uneven number if possible)

Subject Matter Experts (as required)

To minimise bias and preserve impartiality the Manager of the

area in which the event has occurred should not be part of

the ERG or take part in the related ERG decision(s).



Workshop flow

31



2. What is it?




Just Culture - does it really deliver?

“We are now undertaking activity that would normally only have resulted from an accident,

but in this case, no-one was hurt and nothing was damaged. The last three weeks have seen

some of the most valuable people-centred safety management activity we have conducted.”

Commanding Officer, RAF Lossimouth

“ We are learning things about ourselves that we normally only learn after a funeral and the

loss of jet”

Senior Engineering Manager, military aviation

“I'm stunned by what’s been culturally acceptable and what I'm learning. We are now

motivated to do and learn more.”

Director of Operations, major International Airline

“I’m shocked and I’m depressed, but at least I know where we are now...plotting the course to

point B has been made easier”

Senior Manager, major aircraft manufacturer



Safety culture maturity KPIs

RAF Air Safety Centre

example...



Does it really deliver?

“Labels transposed, been happening for

years we thought everyone knew it?”



Transitioning to safety performance



Predictive?

© Baines Simmons Limited 2009 Just Culture for safety performance


Poor maintenance

practices, 3, 2%

Poor

troubleshooting

standards, 1, 1%

Servicing error, 22,

12%

Poor inspection

standards, 25, 12%

Misinterpritation of

approved data, 5,

3%

Installation error,

100, 52%

Approved data not

followed, 28, 14%

Damage , 2, 1%

Tools left on

aircraft, 1, 1%

Unrecorded work,

2, 1%

Work not certified

before operation of

aircraft, 1, 1%

Error type



6

11

24

29

39

66

67

71

72

79

100

140

0 20 40 60 80 100 120 140

N/A

Other

Job / Task

Equipment / Tools / Parts

Environment / Facilities

Communication Issues

Technical Knowledge/Skills

Leadership / Supervision

Organizational Factors

Aircraft Design/Configuration/Parts

Factors Affecting Individual Performance

Information

Summary of Contributing Factors

Installation error



2

2

2

8

9

13

15

17

26

37

0 5 10 15 20 25 30 35 40

Inappropriate for the task

Misinterpretation

N/A

(blank)

Too much / conflicting Information

Not Understandable

Unavailable / inaccessible

Incorrect

Other

Information not used

Information

Installation error



4

4

4

5

6

12

18

19

24

0 5 10 15 20 25

N/A

Peer pressure

(blank)

Other

Memory lapse

Fatigue

Complacency

Workplace distractions / interruptions

Time constraints


Installation error



1

2

2

3

5

5

8

10

15

25

0 5 10 15 20 25

Work process/procedure

Complex

Incorrect

N/A

Not User Friendly

(blank)

Inaccessible

Aircraft configuration variability

Other

Easy to install incorrectly

Aircraft Design / Configuration / Parts

Installation error



2

3

3

4

4

4

7

10

13

19

0 2 4 6 8 10 12 14 16 18 20

N/A

Time contraints

Workplace distractions/interuptions

Company policies

Corporate change/ restructuring

Other

Work process / procedure not documented

Company work processes

Quality of support from technical organisations

Work process / procedure not followed


Installation error



1

1

2

3

4

5

10

10

16

18

0 2 4 6 8 10 12 14 16 18

Inadequate prio rit isat io n o f wo rk

Wo rk pro cess/ pro cedure

N o t eno ugh staff

Unrealist ic att itude / expectat io ns

N / A

Inadequate delegat io n / assignment o f task

Other

(blank)

Inadequate planning / o rganisat io n o f tasks

A mo unt o f supervisio n


Installation error



2

2

2

3

3

4

5

6

6

29

0 5 10 15 20 25 30

N/A

Planning/orgainization of tasks


Inadequate skills

Skills

Inadequate Airline Process Knowledge

Inadequate task planning

Inadequate Aircraft System Knowledge

Other

Inadequate task knowledge

Technical Knowledge / Skills

Installation error



1

1

1

3

4

9

10

11

12

12

0 2 4 6 8 10 12

Inadequate task kno wledge

Quality o f suppo rt fro m technical o rganisat io ns

Wo rk pro cess/ pro cedure no t do cumented

N / A

B etween Lead and M anagement

B etween maintenance crew and lead

B etween departments

B etween shif ts

B etween engineering staff

Other


Installation error



1

2

2

3

4

4

4

5

5

6

0 1 2 3 4 5 6

Workplace distractions/interuptions

Cleanliness

Rain

(blank)

Hot

N/A

Other

Cold

Lighting

High noise levels


Installation error



1

1

1

1

2

2

4

4

5

6

0 1 2 3 4 5 6

Not understandable

Not Used

Unreliable

Work group normal practice (norm)

Information not used

Unsafe

Inappropriate for the task

N/A

Unavailable / inaccessible

Other


Installation error



2

3

3

3

4

4

6

7

10

10

0 1 2 3 4 5 6 7 8 9 10


Complex / confusing

Work process/procedure not followed

(blank)

Complacency

N/A

Different from other similar tasks

Other

New task or task change

Repetitive / monotonous

Job / Task

Installation error



6

11

24

29

39

66

67

71

72

79

100

140

0 20 40 60 80 100 120 140

N/A

Other

Job / Task




Technical Knowledge/Skills



Aircraft Design/Configuration/Parts


Information

Summary of Contributing Factors



Lastly, please remember…

FAiR has been designed to offer a ‘handrail’ to aid

organisations

Meant to assist organisations practical apply sound Human

Factors theory, especially in the area of matching behaviours

to interventions

It is absolutely dependent on:

a structured process

‘leadership’ buy-in

and the competence of individuals using it.



Conclusion

A proactive safety culture that is founded upon a Just Culture

Being Just is the bedrock of safety performance

Encourages openness and proactive reporting of hazards

Enables you to discover what people have to do to get the job

done

Facilitates Risk Based Decision Making

If commonly applied will be successful across international

businesses.



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