safety culture: why is it essential and how can we improve it? … culture... · 2015-10-10 ·...
TRANSCRIPT
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)