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Safety Culture Process

Barry KIRWAN - EUROCONTROL barry.kirwan@eurocontrol.int

European Organisation for the Safety of Air Navigation

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Real Safety Culture, real safety issues.

A controller makes a mistake, but no A controller makes a mistake, but no one sees it. Does he report it?one sees it. Does he report it?

A supervisor sees ‘cowboy’ A supervisor sees ‘cowboy’ behaviour by a controller, but the behaviour by a controller, but the supervisor is no longer connected supervisor is no longer connected with the teams. Does he act?with the teams. Does he act?

Two Department Heads (Ops & Eng) Two Department Heads (Ops & Eng) know their departments don’t work know their departments don’t work well together. Do they ignore it?well together. Do they ignore it?

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The Safety Culture Process

Preparation Meeting (Oct)Preparation Meeting (Oct) Launch (Jan)Launch (Jan) Questionnaire (Jan)Questionnaire (Jan) First Diagnosis (March)First Diagnosis (March) Workshops (April)Workshops (April) Analysis & RecommendationsAnalysis & Recommendations Presentation to Management Presentation to Management

(May)(May) Report (June)Report (June) Presentation to Staff (June)Presentation to Staff (June) Action Plan (Sept)Action Plan (Sept) 0%

20%40%

60%80%

100%

My management is committed to safety(G7)

My colleagues are committed to safety(G4)

The organisation tries to do more than just meet the minimum safety regulations(G9)

4%

7%

6%

14%

4%

17%

81%

89%

78%

HOW STRONG IS THE COMMITMENT TO SAFETY?

Unfavourable Neutral Favourable

Results of a Safety Culture Survey at

XXXXXVersion: 1.0

Date: 3 June 2011

Confidential

0%20%

40%60%

80%100%

Changes to the organisation and ATC system do not increase safety-related risks(M18)

I am concerned that an operational incident will happen in the near future(C3*)

I am concerned that equipment, important to operational safety (e.g. radar) will fail in the near

future(E12*)

11%

25%

63%

33%

23%

19%

56%

52%

19%

COULD YOUR ANSP BE INVOLVED IN A SERIOUS SAFETY INCIDENT?

Unfavourable Neutral Favourable

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The Process – High Level

Decide to embark on the Safety Culture ProcessDecide to embark on the Safety Culture Process Elect a champion, back the championElect a champion, back the champion Engage internal stakeholdersEngage internal stakeholders Launch the ProcessLaunch the Process Ensure good participationEnsure good participation Expect a mixture of newsExpect a mixture of news

• Strengths• Areas for improvement

Give feedback to participantsGive feedback to participants Build on the ResultsBuild on the Results

Prepare

Launch

Run

Learn

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Step 1. Prepare (1/2)

Consider Benefits & CostsConsider Benefits & Costs• Better risk picture & management; Staff engagement in

safety vision• Costs of staff involvement (time); External supply costs

Consider Breadth & TimingConsider Breadth & Timing• Participation: ATCOs, Engineers, Managers, All?• Locations: HQ, ACCs, Towers, other?• Other initiatives? Ongoing problems/issues?

Elect Champion & Support ChampionElect Champion & Support Champion• Trusted by both staff & management; visible

management commitment (CEO/Board announcement); Inform Internal StakeholdersInform Internal Stakeholders

• Heads of Departments; Staff Committees; Unions; etc.

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Step 1. Prepare (2/2)

Select ApproachSelect Approach• Questionnaire; focus groups

Select TechniqueSelect Technique• Off-the-shelf; Bespoke• Eurocontrol; Keil Centre; other

Select Outside AgencySelect Outside Agency• Eurocontrol; Consultancy; University

Determine Launch DateDetermine Launch Date• Best if not during summer period

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Step 2. Launch

Management BriefingManagement Briefing All Staff BriefingAll Staff Briefing Multi-CentreMulti-Centre Explain Explain Why, What, So WhatWhy, What, So What Stress independence/anonymityStress independence/anonymity Practical Points (POCs; Timings)Practical Points (POCs; Timings) Survey team familiarisation and Survey team familiarisation and

observation, walk-rounds, etc.observation, walk-rounds, etc.

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Questionnaire Analysis

Identify Key Issues

Analysing the Issues

Prioritising the Issues

Solution proposals

Understandingthe Issues

Feedback to Management & Staff

Workshops

After the workshops

Survey the population1. General section2. Controllers/Assistants3. Maintenance/Engineering4. Managers

Improvement Strategy

Step 3: Running the Survey - The Heart of the Process

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SAFETY CULTURE

Commitment

Teaming

Learning &Reporting

Responsibility

Involvement

Communications& Trust

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Questionnaires

Below is a list of statements regarding safety issues that are relevant to your role in the organisation. Please indicate the extent to which you agree/disagree with each one by circling one number on each line. We want your opinion about how your organisation currently works.

Str

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dis

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ree

Dis

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Ne

ith

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Ag

ree

Str

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ag

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Comment

1. Even if some equipment is unavailable, we are still required to meet our capacity targets

1 2 3 4 5

2. The equipment that is available is suitable for my job 1 2 3 4 5

3. In ATC everyone knows there is an accident ‘just waiting to happen’

1 2 3 4 5

4. Maintenance staff understand how equipment failures affect our ability to provide safe air traffic services

1 2 3 4 5

5. I trust the ATC procedures that I use in my job 1 2 3 4 5

6. Maintenance staff perform sufficient system checks 1 2 3 4 5

7. The future plans are adequate for the development of the ATC service

1 2 3 4 5

8. I trust the ATC equipment that I use in my job 1 2 3 4 5

9. We openly discuss incidents in an attempt to learn from them

1 2 3 4 5

10. Controllers would never compromise their responsibility for safety

1 2 3 4 5

11. We are expected to be able to handle safety problems without reducing throughput

1 2 3 4 5

12. We are consulted about changes to the technical/ engineering system that impacts on the way we do our work

1 2 3 4 5

13. There is pressure to use smaller safety margins than I feel comfortable with

1 2 3 4 5

14. It is possible for operational and technical/ engineering systems teams to meet together and discuss potential solutions for past problems

1 2 3 4 5

Controllers

Engineers

Managers

General

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Sample Results: Best 5 items

1

1,3

3,6

3,6

3,3

2,3

2

2,3

3,6

3,9

96,8

96,7

94,1

92,9

92,8

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Only my manager hasresponsibility for safety

Only the Safety Departmenthas responsibility for safety

Each member of staff hasa responsibility to keep up

with changes toprocedures

If I do something wrong, Ican discuss it with my

colleagues withoutworrying about the

consequences

I have confidence in thepeople that I interact with in

my normal workingsituation

% of respondents

% unfavourable

% neutral

% favourable

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Sample Results: Bottom 5 items

38,5

35,5

46,4

53

60,3

20,9

26,1

17,9

15,2

12,2

40,5

38,3

35,8

31,8

27,5

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

We have sufficient safetyexperts and support staff in

house

There is a lack of feedback onthe results of safety initiativesthat we have participated in

The other people in theorganization do not understandour job and the safety roles we

fulfil

Feedback from incidentscomes months or years laterwith few recommendations

Even if the system fails, we arestill expected to achieve thetargets that are set for us

% of respondents

% unfavourable % neutral % favourable

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Focus Group Process

4-6 GROUPS (mixed) + 4-6 GROUPS (mixed) + FacilitatorsFacilitators

Key issuesKey issues• Ensure understanding• Consider causes and

consequences

Potential solution pathsPotential solution paths Key ways forwardKey ways forward Mode: Facilitated ProcessMode: Facilitated Process

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Results of a Safety Culture Survey at NAV PORTUGAL

Version: 3.0Date: 30 April 2007

Safety culture : qualitative and quantitative assessment

Project Coordination:Sílvia Agostinho da Silva

CIS/DEPSO/ISCTE/PORTUGALsilvia.silva@iscte.pt

Output: Confidential Report to ANSP

1. ‘Diagnosis’ of ANSP Safety Culture2. Detailed Results by Group & Region3. Suggested Ways Forward:

Quick wins & longer term solutions

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ANSP Safety Culture Enhancement Strategy

Decide the options and the prioritiesDecide the options and the priorities• Strategic – e.g. safety culture campaigns• Tactical – e.g. improve computerised incident

reporting system

Allocate responsibilities & resourcesAllocate responsibilities & resources Be realistic about the time it can take to Be realistic about the time it can take to

change culturechange culture Track & Monitor ProgressTrack & Monitor Progress Communicate, communicate, communicateCommunicate, communicate, communicate

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Timescale of the Survey Process

00 1m1m 3m3m 6m6m 1yr 1yr 3 years3 years

LaunchLaunch

AnalysisAnalysis

Focus Focus groupsgroups

ImprovementImprovementStrategyStrategy

Mid-termMid-termReviewReview

Strategic reviewStrategic review22ndnd Measurement Measurement

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1. Positive safety culture2. ‘Passion for safety’ 3. High Risk Awareness4. Involvement in Safety

5. Pace of change6. Communications7. Learning from incidents8. Trust between Teams

SAFETY CULTURE

ELEMENTS

RiskAwareness

Teamwork

Communications

Involvement

Commitment &

Responsibility

Learning and Trust

Example ‘Board Level’ Picture

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Example Recommendations

Supervisor is a key asset – re-Supervisor is a key asset – re-assess safety function of assess safety function of supervisor, especially how to supervisor, especially how to support safety culture in the shift support safety culture in the shift ‘teams’‘teams’

Enhance the speed and Enhance the speed and transparency in incident feedback transparency in incident feedback to controllers – and extend the to controllers – and extend the process to maintenance process to maintenance engineersengineers

Deal with certain safety ‘hotspots’ Deal with certain safety ‘hotspots’ identified in the surveyidentified in the survey

Review OJTI training protocols in Review OJTI training protocols in high intensity work situationshigh intensity work situations

Determine top ten ‘hit-list’ of safety Determine top ten ‘hit-list’ of safety issues for the organisationissues for the organisation

Evaluate extent of ‘workarounds’Evaluate extent of ‘workarounds’ Gain more operational involvement Gain more operational involvement

in HAZOPs etc.in HAZOPs etc. Clarify safety responsibilities for all Clarify safety responsibilities for all

staff including corporate staff including corporate managementmanagement

Prioritise safety resourcesPrioritise safety resources Renew Team Resource Renew Team Resource

ManagementManagement

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Support

Getting StartedGetting Started• White Paper; ‘Brochure’; Safety Culture

Toolbox Technical SupportTechnical Support

• EUROCONTROL Safety Team; CANSO; FAA • Consultancies (e.g. the Keil Centre in the UK;

NLR in Holland);• Universities (various, e.g. Aberdeen [UK],

Lund [Sweden]; Leiden [Holland] etc.) Continued SupportContinued Support

• EUROCONTROL, CANSO and FAA all have placed Safety Culture as a strategic objective over the next 5 years.

Peer SupportPeer Support• EUROCONTROL planning ANSP regional

workshops in 2009 onwards

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Summary

The measurement of safety culture is relatively matureThe measurement of safety culture is relatively mature There is an agreed process: although some individual There is an agreed process: although some individual

tools may differ, they deliver similar resultstools may differ, they deliver similar results It is not a painful processIt is not a painful process There is support availableThere is support available More and more European Member States signing upMore and more European Member States signing up

Questions?

SafetySafety

CostsCosts