Safety Culture and the Risk Based SMS in Cathay Pacific Airways

CX at a glance

Organizational & Safety Culture Definition

Components

Safety Policy

Risk Based Safety Management System Governance structure

Safety Performance Indicators (SPI) & Risk Index Score (RIS) methodology

Safety promotion

Operational Risk Assessment

Conclusion

Questions / discussion AGENDA

International airline registered and based in Hong Kong Scheduled passenger and cargo services 179 destinations served in 42 countries and territories. Dragonair – Full subsidiary (41) / Air Hong Kong – JV with DHL (11)

CX: 136+ aircraft (747-400, B747-8, 777-200/300/300ER, A330/340)

68+ firm orders

Total CX & subsidiary staff = 31,000+ CX is a founder member of the One World alliance.

2.4M + passengers / month

Cathay Pacific Airways – At a Glance

CPA – AT A GLANCE

The culture of an organization is the shared values (what is important) and beliefs (how things work) that interact with an organization’s structure and systems to produce behavioral norms (the way we do things around here).

The safety culture is a sub component of organizational culture.

Can be defined as a set of values, beliefs, behaviors and assumptions concerned with minimizing the exposure to danger and risk.

In practice this definition means, “this is the way we do things around here to minimize exposure to conditions considered to be a risk to a continued safe operation”.

Organizational & Safety Culture

SAFETY CULTURE

Basic Definition

With almost 50 crew nationalities on board our aircraft, as well as engineers and ground staff working at many ports around the world, so ensuring an effective

‘safety culture’ is essential

SAFETY CULTURE

A prerequisite for any airline to be considered the ‘world’s best’ is that it operates safely. The Cathay Pacific Vision Statement clearly demonstrates the Company’s formal and open commitment to establish safety as a core value and ensure that safety comes first.

Strong link to CX Vision Statement

SAFETY CULTURE

Safety is our

number-one

priority at Cathay Pacific

Ultimate accountability

for safety rests with the

Chief Executive

Responsibility for safety

lies with each and

every person in

the airline

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The Safety Policy is a tangible indication that senior management is committed to safety and expect high safety performance from all staff. It also articulates what type of behaviors [or cultures] we should all aspire to, to create the correct organizational culture that in turn will lead to an effective “safety culture” within the organization. Just Reporting Learning Informed

SAFETY CULTURE

Safety Culture

Safety Culture Supported by CX Safety Policy

SAFETY CULTURE

COMPONENTS OF CX SAFETY CULTURE

An ORGANIZATIONAL culture

where a “safety comes first” philosophy forms the basis of all our

activities”

SAFETY CULTURE

COMPONENTS OF CX SAFETY CULTURE

An INFORMED culture •People understand the hazards and risks involved in their operation. •Staff work to continuously identify and manage threats to safety. •Apply appropriate risk management systems and processes routinely as part of all decision making when considering significant changes (new systems and procedures) for safety implications in order to identify and manage potential hazards, threats, and risks. •Essential if you wish to be PREDICTIVE.

SAFETY CULTURE

COMPONENTS OF CX SAFETY CULTURE

A JUST culture Where it is accepted that mistakes and errors are unintentional and can

be made by anyone. Where acceptable and unacceptable behaviors are clearly defined and

communicated. Where “non-punitive reporting” is encouraged so both hazards and

errors can be reported without fear of any retribution. However, ……with the clear understanding that reckless behavior &

deliberate violations are not tolerated.

CX’S VIEW ON SAFETY CULTURE

COMPONENTS OF CX SAFETY CULTURE

A REPORTING culture People are encouraged to openly report safety issues and concerns. Take the initiative to report hazards, threats and errors (proactively). Only when safety concerns are reported, can they be analyzed to enable appropriate and timely mitigations to be implemented. Reporting is closely linked to Just Culture.

CX’S VIEW ON SAFETY CULTURE

COMPONENTS OF CX SAFETY CULTURE

A LEARNING culture We learn from our own mistakes and those made by others (accident reports). REACTIVE Ensuring we have effective internal incident investigation & recommendation processes. REACTIVE Where staff are continually updated on safety issues and challenges by management. PROACTIVE Staff are encouraged to develop their own skills and knowledge to enhance organizational safety. PROACTIVE

What is one the most vital factors within an organization to generate an effective

safety culture?

SAFETY CULTURE

Top-Down Support with Tangible Actions

“I put the safety of our passengers and crew front and centre of my responsibilities as chief executive of Cathay Pacific.”

“Safety is not a department or a meeting. It is a culture of open communication and cooperation with everyone working together every day to make our airline the safest it can be.”

John Slosar Chief Executive Cathay Pacific Airways

Memo to all staff - Jan 2012

SAFETY CULTURE

Commitment to safety and to the strengthening of safety culture at the top of an organization is the first and vital ingredient in achieving excellent safety performance. In CX, airline safety is put clearly and unequivocally in first place in requirements from the top of the organization, and there is absolute clarity about the company’s safety philosophy. Safety Priority (e.g. budget) Opportunities for safety communication Support to safety personnel Appropriate resource and manpower Clearly articulated and displayed safety policy Open door policy for safety issues encouraged

Leadership / Management Commitment

SAFETY CULTURE

SAFETY CULTURE

1. You need a system…………………………………………………………………………..

2. An effective Risk Based Safety Management System (SMS)

Which is integrated across the airline and directs us to the areas that need attention

3. Assists us in generating a strong & effective Safety Culture among ALL staff, crew and management

The Safety Management System (SMS) Jigsaw

Flight Data Analysis

Program

Safety

database

Safety review

committees

Safety

investigations

Publications &

resources

Safety reporting

system

Hazard identification

& risk

management

Safety education

& training

Quality

Audits

Corporate Safety

Department

Safety Policy &

Manual

Safety Monitoring &

measurement

Flight Data

Analysis

FRMS

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Safety Committee System

Responsibility and accountability needs to be cascaded throughout the entire organizational structure. In CX, a safety committee system has been developed to assist with managing the safety of the Airline. The safety committee system ensures that we regularly measure and review our safety performance, goals and objectives.

UPHOLD CX SAFETY CULTURE

Risk Based SMS

Board Safety Review Committee (BSRC) Group Airline Safety Review Committee (GASRC) Airline Safety Review Committee (ASRC) Safety Action Group (SAG) – FOP, ENG, GND, CAB, FRMS, OH&S

The ASRC has been meeting monthly for over 44 years

Key to the Committee System

Risk Based Safety Performance Monitoring Utilizes Safety Performance Indicators (SPI) & Risk Index Score (RIS) Methodology Use a range of indicators to monitor performance and continually strives to find better

ways of improving hazard control mechanisms.

SAFETY CULTURE

Full integration into CX SMS process / Committee System Utilised by relevant operational departments and their associated safety

committees and/or safety action groups as part of the CPA Safety Management System

Driven by Two dimensions (Event Rate + Risk Index Score - RIS) Trending components incorporated which are linked to the safety

performance threshold Drill down or trending capability Better visibility of the composition of the safety risk Strong Stake-holder buy-in

CX SMS SPI Program – FEATURES

SMS DEVELOPMENT

Indicator Set – Developed for each Committee / SAG Through a systemic review of the operational and organizational issues which could impact upon operational safety. These factors include but are not limited to: > Critical safety events > Known areas of safety risk (i.e. risk register) > Accident / Near-miss reporting and investigation > Regulatory compliance – CAD 382 > Industry standard and data exchange (e.g. IATA, AAPA) > Inspection & auditing requirements & reports > etc.

First Step - What to Monitor? What SPI’s do we Need?

SPI – Components

Safety Events

Risk Register

Industry Standard / Data

Regulatory Compliance

Inspection / Audit Requirement

Second Step - Set Thresholds for all the Metrics

A threshold metric compares safety data using a descriptive / trended metric to one or more specified “thresholds” or tolerances. The thresholds/tolerances are designed to highlight the need for action to address a safety issue. When the tolerance level is exceeded, this indicates that an intervention is warranted. Thresholds are set via various means including expert judgment, benchmarking or by employing appropriate statistical techniques. When the latter approach is employed, CPA defines the target threshold as 1 Standard Deviation above from the historical average (18 months).

Risk Assessment

25

Risk Index Score (RIS) – Methodology

Risk Component Value

Risk Index Score

Severity bias – Geometric progression of 3 RIS = RCV (Likelihood) x RCV (Severity)

RIS - Methodology

Risk classification system based on Numerical Value Convert categorical risk label into numerical risk rating Better discrimination within the categorical labels Primary unit of measurement used by CX Safety

Performance Indicators Predicate on CX 5 x 5 operational risk matrix and

complement existing risk methodology Apply to all safety report / audit data recorded in AQD Aim at providing a more meaningful, measurable and

transparent mechanism to communicate the operational safety risk

Is NOT Rocket science. Intuitive, quick to assimilate

Risk Index Score (RIS) – Key Features

RIS – Key Features

Risk Index Score (RIS) – Methodology

AQD Data listing Snapshot (Example)

RIS - Methodology

Driven by Two dimensions (Event Rate + Risk Index Score - RIS)

Full integration into CX SMS process Utilised by relevant operational departments and their associated safety committees

and/or safety action groups as part of the CPA Safety Management System Extract the key element from the data for high level monitoring

Effective Data Analysis and Monitoring

Safety Data Analysis

CX RISK OVERVIEW

- (MOR-AHQ) PAX CHECKED BAGS FOUND FULL OF LITHIUM BATTERIES DURING TRANSIT - BKK

- (AHQ) DISEMBARKED AT OUTER BAY - WHEELCHAIR PAX CARRIED DOWN A/C STAIRS - BOM

- (CGO) MAIN DECK LOADER WITH MAINTENANCE CHECK 4 MONTHS OVERDUE - SIN

- (MOR-ENG) A/C ROLLED BACK DURING PUSHBACK TRACTOR CHANGE - HKG

20130208(REV0)

UPHOLD CX SAFETY CULTURE

Safety Information Promulgation Raise staff awareness of safety current issues we face: Safety Magazine (Kai Talk) Safety Bulletin Intranet Safety Feedback Flight Data Analysis Program Report Provision of Flight Data debrief/review for flight crew Safety Branding

UPHOLD CX SAFETY CULTURE

Operational Risk Assessment The Cathay Pacific SMS is a ‘risk based’ system. All staff are requested to assist with

the identification of safety threats, risks and hazards. Once all of these are known, the risks can be managed to an acceptable level.

Strive to move your organizational culture towards a generative safety culture by securing and clearly articulating and demonstrating top-down support.

Remember the journey is never ending - “If you are convinced that your organization has a good safety culture, you are almost certainly mistaken. Like a state of grace, a safety culture is something that is striven for but rarely attained” (James Reason)

Consider how to turn your SMS into a risk-based SMS so that it will tell you where to focus your attentions and resource.

Finally = KISS!

Conclusion

CONCLUSION