Safety Culture Informed, Just and Fair

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Safety CultureInformed, Just and Fair

• Patrick Hudson
• ICAO/Leiden University

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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

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How Safe is Aviation?

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

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Aviation isnt that safeUS data 1997
Lost Workday Incidents per 100 Employees in US
9 8 7 6 5 4 3 2 1 0
Frequency Rate
Courtesy DuPont
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It doesnt get better - 2001
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Safety CultureThe Added Ingredient

• Safety Management Systems provide a systematic
  approach to safety
• Minimum standards can be defined but this is not
  the best way to obtain the extra benefits
• A good safety culture fills in the gaps
• Sound 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

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Safety Culture indicators
chronic unease safety seen as a profit centre new
ideas are welcomed
GENERATIVE
resources are available to fix things before an
accident management is open but still obsessed
with statistics procedures are owned by the
workforce
PROACTIVE
we cracked it! lots and lots of audits HSE
advisers chasing statistics
CALCULATIVE
we are serious, but why dont they do what
theyre told? endless discussions to re-classify
accidents Safety is high on the agenda after an
accident
REACTIVE
PATHOLOGICAL
the lawyers said it was OK of course we have
accidents, its a dangerous business sack the
idiot who had the accident
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The Evolution of Safety Culture
GENERATIVE safety is how we do business round
here
Increasing Informedness
PROACTIVE we work on the problems that we still
find
CALCULATIVE we have systems in place to manage
all hazards
REACTIVE Safety is important, we do a lot every
time we have an accident
Increasing Trust Accountability
PATHOLOGICAL who cares as long as were not caught
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Characteristics of a Safety Culture

• Informed - managers know what is really going on
• Reporting - the workforce is willing to report
  their own errors and near misses
• Just - a no blame culture, with a clear line
  between the acceptable and unacceptable
• Wary - ready for the unexpected
• Flexible - operates according to need
• Learning - willing to adapt and implement
  necessary reforms

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How to create a Safety Culture

• Depends on where you are starting from -
  unfortunately you cant get to the end in one go,
  all the steps have to be traversed
• Becoming a Safety Culture involves
• acquiring a set of safety management skills
• and then maintaining them
• The two major factors are informedness and trust,
  and these have to be developed over time
• Be systematic (Safety Management Systems are a
  start) and then learn to operate with the unknown
  as well

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Developing a Safety CultureInformed and Learning

• Agree on ways to analyse incidents to reveal both
  individual and system issues
• Develop reporting systems that are easy to use
  (compact, open-ended, impersonal)
• Encourage the workforce (air and ground) to
  realise that incidents are worth reporting
• Practice management in wanting to know from near
  misses before they become accidents

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A Reporting Culture

• In order to get the information we need, we need
  to be told
• This often requires people to admit their own
  errors - this is personally difficult at best
• The workforce will not tell what they have done
  if they are afraid of the consequences
• Pathological and Reactive cultures shoot the
  messenger
• Generative organisations train messengers!

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Developing a Safety CultureJust

1. Get rid of the idea that blame is a useful
   concept (this is hard to do)
2. Define clear lines between the acceptable and the
   unacceptable
3. Have those involved draw up the guidelines, do
   not impose from above if you want them to be
   accepted
4. Have clear procedures about what to do with other
   forms of non-compliance

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Why is Blame so easy?
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Human Error - The Problem

• If an accident happens people want to blame
  someone
• Insurance - who pays?
• Criminal responsibility - who goes to prison?
• Technical failures are usually seen as less
  reprehensible
• This often applies even with near misses

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Blame

• Blame is something that is attached to
  individuals
• What about objects?
• What about non-human entities?
• Blame is associated with causality
• People attribute cause to other people
• Bad people have bad accidents

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Attribution

• Fundamental Attribution Error
• Individuals attribute causes of their own actions
  to external causes
• They attribute causes of the actions of others to
  personal factors in those individuals
• There is a belief that The World is Just
• This leads to the idea of accident proneness
• Bad things happen to bad people
• Also called Outcome bias

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Hindsight Bias

• Hindsight Bias (Fischhoff, 1975)
• One knew it all along
• Known branches are over-estimated
• We now know the outcome, we didnt before
• The scenario now seems easy to generate and
  therefore was easy before the event
• In advance, bad outcomes are evaluated as less
  likely, especially if you feel you can control
  matters
• If you knew the best options, and could have
  controlled for them, then selecting any other
  must be incompetent!

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The Illusion of Free will

• People believe they have free will
• They can always choose what they will do
• They can foresee the consequences of their
  actions and act accordingly
• They attribute this to others
• They commit the fundamental attribution error
• Hindsight bias makes the choices seem less and
  more obvious than at the time
• They regard human failures as more avoidable than
  technical failures

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The Law - Prosecution

• Prosecutors are tasked with finding one or more
  individuals to prosecute
• Prosecutors will only proceed if there is a
  reasonable chance of success
• The closer to the event the harder the evidence
• The further from the event, the more doubt can be
  introduced about alternative causes
• Any amount of specific evidence may be sufficient
  in a criminal case

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Corporate Manslaughter

• Targeting company bosses is the new approach
• Based on a duty of care concept - bosses have a
  duty to ensure safety
• Lord Denning defined the Guiding Mind principle
• This has proved hard to obtain prosecutions
• The principle of Executive Authority makes it
  easier to prosecute (When the executive says
  jump, subordinates ask how high, not vice-versa)

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Who is convinced?

• Prosecutors
• Police
• Investigators
• Judges
• Juries (in jury systems)
• Colleagues
• The accused themselves

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Thinking about a Just Culture

• The need to have rules and procedures
• The standard approach to non-compliance
• Marx and Reasons Just Culture
• A new approach - Hearts and Minds
• Types of violation - Managing Rule Breaking
• Roles of those involved - Managers to Workers
• Individuals - the reasons for non-compliance
• Solutions - from praise to punishment
• From Just Culture to Fair Culture

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The need for rules

• Many hazards cannot be controlled by hardware or
  design
• Other hazards are more easily controlled by
  administrative approaches
• There are three levels of specification
• Guidelines
• Descriptions and sequences
• Work instructions
• Failure to follow procedures temporarily negates
  the control of the management system
• The assumption is that all the rules will be
  followed

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The Simple View -How to manage non-compliance

• Rules and procedures are there for a purpose
• Personnel are expected to know them and are
  clearly expected to comply with all relevant
  procedures
• Failures to comply represent a deliberate failure
  of an individuals performance contract
• Such failures cannot be tolerated, because the
  HSE-MS relies upon compliance
• Non-compliance is best managed by making people
  aware of the personal consequences, from written
  warnings to dismissal

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Review of the Simple View

• There is an assumption that all rules and
  procedures are optimal and not in need of
  improvement
• The US Nuclear INPO studies found that 60 of
  procedural problems were due to incorrect
  procedures
• The requirement is for unquestioning compliance
  by a worker
• The INPO studies found that most people did
  follow procedures, even when they were incorrect
• A weaker version of such requirements may require
  challenge
• This is often based upon following the incorrect
  rule or procedure first, with subsequent challenge

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The Just Culture - Version 1

• Originated by David Marx - a Boeing engineer and
  also a lawyer
• Propagated by Prof James Reason
• Starts 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 blame
• If 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

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Review of Just Culture v.1

• The model appears to assume individual guilt
  unless proven otherwise
• The drawing, going from left to right, implies
  visually where priorities lie. The amount of
  space devoted to discipline does the same
• There 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

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The Just Culture - Version 2

• Empirical studies of non-compliance showed a
  complex picture
• 6 different types of violation
• Managers and supervisors have a role as well as
  the violating worker
• Individuals will be working with a variety of
  intentions, from the companys interest to their
  personal gain
• Solutions range from improving the system to
  ensuring compliance

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Example DAL 39

• An example of what happens today in Western
  Europe
• Criminal prosecution of three air traffic
  controllers
• All 3 found guilty of a misdemeanor at Court of
  Appeal
• No punishment because of the system failures, but
  no prosecution of management

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DAL 39

• A Delta 767 aborted take-off at Amsterdam
  Schiphol on discovering a 747 being towed across
  the runway
• Reduced visibility conditions (Phase - B)
• The tower controller was in training, under the
  tower supervisor
• There was another trainee and of the 11 people in
  the tower five were changing out to rest
• The incident happened between the inbound and
  outbound morning peaks

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Runway Incursion (1998)
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The DAL 39 event scenario
Tunnel brought into use without briefings
Pilots see 747 and abort take-off
Routine violation of tow procedures
Airport decides to change airport structure
Tower combining training and operations during
difficult periods
Controller gives clearance without assurance of
tow position
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Why did all this happen - 1?

• Tow was in violation, but this appears to be
  routine
• No clear protocols for ground vehicles and no
  hazard analysis
• Different language for aircraft (English) and
  ground vehicles (Dutch)
• Poor quality of ground radio
• Clearances appeared to be unlimited once given
• Tower supervisor was also OTJ trainer in the
  middle of the rush hour
• Altered control box not introduced to ATC staff

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Why did all this happen - 2?

• No briefings about alterations at Schiphol (It
  has been a building site for years)
• Too many trainees in the tower in rush hour under
  low visibility conditions
• Differences in definition of low visibility
  between aerodrome and ATC
• No management apparent of the change in use of
  the S-Apron
• No operational audits by LVNL or Schiphol, of
  practice as opposed to paper
• Schiphol designed requiring crossing and the use
  of multiple runways for noise abatement reasons

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Could this have been known in advance?

• Many problems are known in advance
• If no one tells they will certainly happen again
• If people fear prosecution and other consequences
  of admitting their errors, will they tell?
• Without reporting, we are doomed to wait until we
  have an accident that everyone can see

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Learning from Errors requires Trust
International oversight
Safety improvements
Lessons learned
National Legislation
Analysis
Statistics
Incident Reports
Trust
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What happens when prosecution takes place?

• After the DAL-39 case, ATCOs reduced the number
  of reports about ATC errors
• They continued to report pilot errors
• They were no longer being prosecuted

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What next?

• It became clear that a new approach was needed
• The old model was even found to be the cause of a
  major accident!
• All types of errors and violations need to be
  considered
• Positive reporting should be rewarded
• There are still actions that everyone agrees are
  unacceptable (Reckless, personal)

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Shells new model

• Shell decided that the concept of the Just
  Culture needed to be extended
• To cover rewards for good behaviours
• To reflect the differences in types of violations
  and errors
• To highlight the responsibilities of both
  individuals who break the rules and their
  managers who condone or do not want to know

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Decision Flowchart
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Consequences

• All actions now have consequences
• These apply both to the individual and their
  managers
• Distinguishing different types of violation is
  essential
• Everyone has to agree to the process and the
  consequences

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Conclusion

• Safety cultures make the difference between a
  mechanical application of SMS and full
  implementation that obtains the maximum benefits
• A Just and Fair Culture is essential for
  reporting
• Without reporting no one knows what is going on,
  until it is too late