Safety Culture Informed, Just and Fair

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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 for a Just Culture Why it is complicated? What if it goes wrong? Conclusion. How Safe is Aviation?. - PowerPoint PPT Presentation

Transcript of Safety Culture Informed, Just and Fair

  • Safety CultureInformed, Just and FairPatrick HudsonICAO/Leiden University

  • StructureHow safe is aviation?Safety cultureThe elements of a safety cultureThe need for a Just CultureWhy it is complicated?What if it goes wrong?Conclusion

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

  • Aviation isnt that safeUS data 1997Lost Workday Incidents per 100 Employees in USFrequency Rate9876543210Courtesy DuPont

  • It doesnt get better - 2001

  • Safety CultureThe Added IngredientSafety Management Systems provide a systematic approach to safetyMinimum standards can be defined but this is not the best way to obtain the extra benefitsA good safety culture fills in the gapsSound 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 PATHOLOGICALREACTIVECALCULATIVEPROACTIVEGENERATIVEchronic uneasesafety seen as a profit centrenew ideas are welcomedwe are serious, but why dont they do what theyre told?endless discussions to re-classify accidentsSafety is high on the agenda after an accidentthe lawyers said it was OKof course we have accidents, its a dangerous businesssack the idiot who had the accidentresources are available to fix things before an accidentmanagement is open but still obsessed with statisticsprocedures are owned by the workforce we cracked it!lots and lots of auditsHSE advisers chasing statistics

  • The Evolution of Safety CulturePATHOLOGICALwho cares as long as were not caughtREACTIVESafety is important, we do a lot every time we have an accidentCALCULATIVEwe have systems in place to manage all hazardsPROACTIVEwe work on the problems that we still findGENERATIVEsafety is how we do business round hereIncreasing Trust & AccountabilityIncreasing Informedness

  • Characteristics of a Safety CultureInformed - managers know what is really going on Reporting - the workforce is willing to report their own errors and near missesJust - a no blame culture, with a clear line between the acceptable and unacceptableWary - ready for the unexpectedFlexible - operates according to needLearning - willing to adapt and implement necessary reforms

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

  • Developing a Safety Culture:Informed and LearningAgree on ways to analyse incidents to reveal both individual and system issuesDevelop reporting systems that are easy to use (compact, open-ended, impersonal)Encourage the workforce (air and ground) to realise that incidents are worth reportingPractice management in wanting to know from near misses before they become accidents

  • A Reporting CultureIn order to get the information we need, we need to be toldThis often requires people to admit their own errors - this is personally difficult at bestThe workforce will not tell what they have done if they are afraid of the consequencesPathological and Reactive cultures shoot the messengerGenerative organisations train messengers!

  • Developing a Safety Culture:JustGet rid of the idea that blame is a useful concept (this is hard to do)Define clear lines between the acceptable and the unacceptableHave those involved draw up the guidelines, do not impose from above if you want them to be acceptedHave clear procedures about what to do with other forms of non-compliance

  • Why is Blame so easy?

  • Human Error - The ProblemIf an accident happens people want to blame someoneInsurance - who pays?Criminal responsibility - who goes to prison?Technical failures are usually seen as less reprehensibleThis often applies even with near misses

  • BlameBlame is something that is attached to individualsWhat about objects?What about non-human entities?Blame is associated with causalityPeople attribute cause to other peopleBad people have bad accidents

  • AttributionFundamental Attribution ErrorIndividuals attribute causes of their own actions to external causesThey attribute causes of the actions of others to personal factors in those individualsThere is a belief that The World is JustThis leads to the idea of accident pronenessBad things happen to bad peopleAlso called Outcome bias

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

  • The Illusion of Free willPeople believe they have free willThey can always choose what they will doThey can foresee the consequences of their actions and act accordinglyThey attribute this to othersThey commit the fundamental attribution errorHindsight bias makes the choices seem less and more obvious than at the timeThey regard human failures as more avoidable than technical failures

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

  • Corporate ManslaughterTargeting company bosses is the new approachBased on a duty of care concept - bosses have a duty to ensure safetyLord Denning defined the Guiding Mind principle This has proved hard to obtain prosecutionsThe principle of Executive Authority makes it easier to prosecute (When the executive says jump, subordinates ask how high, not vice-versa)

  • Who is convinced?ProsecutorsPoliceInvestigators JudgesJuries (in jury systems)ColleaguesThe accused themselves

  • Thinking about a Just CultureThe need to have rules and proceduresThe standard approach to non-complianceMarx and Reasons Just CultureA new approach - Hearts and MindsTypes of violation - Managing Rule BreakingRoles of those involved - Managers to WorkersIndividuals - the reasons for non-complianceSolutions - from praise to punishmentFrom Just Culture to Fair Culture

  • The need for rulesMany hazards cannot be controlled by hardware or designOther hazards are more easily controlled by administrative approachesThere are three levels of specificationGuidelinesDescriptions and sequencesWork instructionsFailure to follow procedures temporarily negates the control of the management systemThe assumption is that all the rules will be followed

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

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

  • The Just Culture - Version 1Originated by David Marx - a Boeing engineer and also a lawyerPropagated by Prof James ReasonStarts with assumption of deliberate violation (e.g. sabotage) by individuals (Marx found about 10%)Next employs the substitution test (would others have done the same?) to check for individual vs system blameIf there is no evidence that an individual was reckless and there is no history of previous non-compliance, then define non-compliance as blame-free

  • Review of Just Culture v.1The model appears to assume individual guilt unless proven otherwiseThe drawing, going from left to right, implies visually where priorities lie. The amount of space devoted to discipline does the sameThere 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 comply

  • The Just Culture - Version 2Empirical studies of non-compliance showed a complex picture6 different types of violationManagers and supervisors have a role as well as the violating workerIndividuals will be working with a variety of intentions, from the companys interest to their personal gainSolutions range from improving the system to ensuring compliance

  • Example DAL 39An example of what happens today in Western EuropeCriminal prosecution of three air traffic controllersAll 3 found guilty of a misdem