Safety Culture: Why is it essential and how can we

improve it?

Gary Lloyd Senior Safety Consultant

NATS

Safety Management – Global Principles

Slide 2

Safety Culture – Maturity Indicators

(Adapted from Westrum, 1992)

Why waste time on safety?

We’ll do something when we have an accident

We have systems in place to manage similar risks

We are always on the alert for risks that might emerge

Managing risk and safety is integral to everything we do

Pathological Reactive Calculative Proactive Generative

How safe are we…

And how do we know?

Challenging Our Assumptions

10’s of Minor

Incidents

100’s of

Near-Incidents

1 Major

Incident

Th

e “

In

cid

en

t Ic

eb

erg

”

Organisational Factors

Just Culture Reporting Culture

Learning Culture Flexible Culture

Safety Behaviour Attitude to Safety

Risk Perception

Influence individual

Safety Culture Ingredients

Individual Factors

Influence organisation

SAFETY

CULTURE

Definition of “Just Culture”

• Recognised worldwide as the foundation of a healthy organisational Safety Culture.

• A Definition: • “A culture where staff are not punished

for actions, omissions or decisions taken by them that are commensurate with their experience and training…

• But where gross negligence, wilful violations and destructive acts will not be tolerated.”

What does a Just Culture lead to?

1. Frequent and open reporting is normal…

2. So we continue to learn safety lessons from the past…

3. Risks are openly and honestly discussed

4. Making both the present and future safer…

5. Leaving us with an honest and self analytical approach to who we are…

o and what we want to be.

.

Improving Safety Culture

• “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” – Dr H. James Harrington

• Pearson’s Law – “That which is measured improves. That which is measured and reported improves exponentially.”

• “Every line is the perfect length if you don’t measure it.”

– Marty Rubin

How to measure “Just Culture”? Examples...

1. Safety Incident Reporting • % total reports that are Voluntary

o e.g. NATS 2014: 33% of 7500 reports! • % of incidents resulting in punishment

2. Internal Safety Surveys • # of staff surveyed per year (or # reports) • % issues followed up/resolved • % feedback to comment originator

• What targets should we set? • How can we help each other to achieve them?

Internal Safety Survey – Example of Results

Exercise in Groups: Safety Culture Metrics

1. Identify 3 Safety Culture Metrics for your organisation • Metrics == Measurements • “SMART”: Specific, Measurable, Achievable, Realistic,

Time-bound

2. Set a quantitative Target (# or %) for each

3. Describe how CANSO should promote, support and monitor progress

4. Report back to the workshop

Exercise Output: Selected Metrics & Targets

1. Incident Reporting • Monitor overall # incidents reported; use a standard

reporting schema (e.g. RAT) and look for trends. • Voluntary %: Target at least 10% of total reports to

be voluntary (increase annually). • Minor v Major incidents: Monitor ratio of minor-mod-

major incident reports. Target increase over time. • Target 100% of reports to have evidence of direct

feedback being provided to originator. • Monitor % of reports related to repeat incidents.

Target reduction over time.

Exercise Output: Selected Metrics & Targets

2. Training and Competence • Safety Awareness briefings to 100% of staff at least 2

times/year. • Target 100% of ATC/Eng staff with full evidence of all

required qualifications: education, English, rating, competence, proficiency (if data is available).

3. Internal Safety Surveys • Perform at least one Annual Safety Survey for each of

ATC and Eng (minimum 30 staff each) per year. • 100% of significant findings acted upon. • Feedback supplied to 100% of participants.

Exercise Output: How to Implement Metrics

• Agree a measurement frequency for each Metric o Usually a 6-12 month period

• Secure top-level buy-in o Embed Safety Culture Metrics into top level

organisational KPIs? • Provide support and templates

o Eurocontrol RAT user guide and access information o Safety awareness briefing material o Safety survey template

Group session: Metrics proposed

• %/number of reports received • Clear safety standards/adherance to standards • Are people properly trained • Employee retention • Clearly defined and reported incidents by category (major vs

moderate vs minor) • inform/train organisation of just culture policy • Incidents per every 3 months • Fatigue reports, manpower resources • Type of incidents • Train the trainer on reporting methods • How to enhance the theme of culture in the country • Auditing of CRM

Group session: Metrics proposed

• Measure SMS Implementation • Measure cultural change at top management • Safety survey every 6 months • number of incidents/safety report every month/year • need more safety culture training, measure results of training • Measure outcome of recommendations • Measurement of potential causes of incidents (call sign confusion) • Rate of engineering vs personnel reports • % of people getting feedback on incident reports • Measure cooperation between engineering and operational staff. • Measure Quality Control implementation • % of repeated failures of equipment • Number of reports without resolution or acted on.

Group session: Metrics proposed

• Measure cooperation between engineering and operational staff. • Measure Quality Control implementation • % of repeated failures of equipment • Number of reports without resolution or acted on. • Measure success in recruiting personnel • Monthly reports of student discipline, exam pass fail, grades and

likelihood of success (qualifications, aptitude and proficiency)