The European Organisation for the Safety of Air Navigation

Safety Intelligence

Barry Kirwan

Eurocontrol

Safety Culture in European ATM

Safety Intelligence

• What the CEO understands and thinks about Safety matters to the safety and safety culture of the organisation

• What they ask, what they don’t ask about safety, also matters

• How they Balance Safety against other KPIs matters a great deal

Questions Facing CEOs

• Safety first – but safety is a cost? How do you determine safety expenditure in a cost-conscious industry?

• How do you balance safety with other market drivers: cost-reduction, expansion, capacity, environment … ?

• How is your ANSP performing? What are the lagging and leading Safety Key Performance Indicators for your organisation?

• If your organisation suffers an accident tomorrow, and you find yourself on the news, what are you going to say?

Safety Culture in European ATM

Safety Intelligence is having the right understanding of safety at the top of the ANSP

• The CEO’s attitude to safety affects others’ attitudes and behaviours with respect to safety (Safety Leadership & Culture)

• It is knowing the right questions to ask, and what you can ask your safety director / manager (Tactical Safety Intelligence)

• It is knowing how to balance safety with other KPIs, including political pressures (Strategic Safety Intelligence)

• It is knowing that should an accident happen, you’ll know what to say and do, and have the evidence ready that safety was prioritised appropriately (Being Prepared)

Safety Culture in European ATM

What do CEO’s ask about Safety?

• How many incidents do we have?

• Are they under control?

• Keep me in the picture – no surprises

• Is all ok? Are we safe?

• How is our Safety Maturity?

• Why is there no safety case?

• Have you shown this to the regulator?

• How much will it cost?

• Is this really necessary?

Safety Culture in European ATM

• Figures & Statistics – hard data

• Visual imagery• Comparisons with other

ANSPs• Always come with solutions

as well as problems• Involve Ops beforehand• Argue from the Safety

Strategy, Safety Case, SMS• Safety as a Business

Imperative

• Scare tactics• Adding cost• Looking like a safety clerk• Ethical arguments only• No prior networking• Safety as its own

justification• Breaking trust or blaming

other Board Members• Not explaining well

Winning & Losing Arguments at Board Level

Safety Culture in European ATM

• ‘Authentic’ leadership matters

• ‘Lip service’ will not work, and will lead to distrust

• Better to ‘play it straight’

• If a CEO has uncertainties about safety, work with the Safety Director to resolve them

But…

Not everyone is a Safety Superman

And People are not naïve

Small touches on the steering wheel can have large impacts

The European Organisation for the Safety of Air Navigation

• What are the top five risks for your ANSP?• What are the actions ongoing to tackle them?• A state prosecutor decides to prosecute one of

your controllers for an incident. What do you do?

• Under what contingency conditions should you shut down your airspace?

• One of your safety cases says a new operation is unsafe, but Ops disagrees – how do you query its results?

Tactical Safety Intelligence

• Following a serious near-miss due to controller workload and poor coordination, a restriction has been in place for 5 months which has reduced capacity, and stopped incidents. The CEO of an affected airline asks you when you will remove the restriction.

• You are moving from two old ACCs to a single new ACC. Staff and unions have expressed concerns about safety impacts

Safety Culture in European ATM

A

B

Improvement Route Design

• 1 FAB• 2 ANSPs• Each ANSP with 3

ACC sectors• 1 Route from A to B to

be shortened• New Route however

increases sector demand

How do I make the trade-offs and still remain safe?

‘Strategic’ Safety Intelligence: Balancing safety against other KPIs – achieving the ‘win-win’

The European Organisation for the Safety of Air Navigation11

A CEO Safety Knowledge ChecklistA CEO Safety Knowledge Checklist

– LEGAL– Legal Responsibilities– Regulatory Considerations– SAFETY PROCESSES– SMS & Safety Policy– Just culture policy– Safety Case Process – What ‘the numbers’ mean – Incident investigation process

– SAFETY PERFORMANCE– Safety Maturity Score– Safety Culture profile– Unit Safety Case results– Safety investment projects– ANSP Top (safety) risks– Risk-Reduction Performance– Safety trends– UNDERSTANDING SAFETY– Why incidents happen– Human Factors & Safety – Management contribution to

risk (accident case studies)– European (safety) risks &

future Safety Issues (FABs, SESAR, etc.)

Summary: Where Safety Intelligence ‘Fits’

Safety Culture

SMS

SITactical & Strategic – making key safety-informed decisions

Processes & Procedures – theANSP’s safety competence

The ANSP’s commitmentTo safety, at all levels

European ATM Safety Conference“Keeping Safety First: is that still achievable?”

27-28 October 2010Hosted by SMATSA, Hotel Hyatt Regency Beograd, Serbia

EUROCONTROL

Safety Culture - Leading From the TopSafety Culture - Leading From the TopSverre Quale Sverre Quale

President of the Avinor groupPresident of the Avinor group

Safety Culture in Everyday Work

• Safety an integral part of the business• Genuine interest in safety -> good

role model• Building competence – influencing

behaviour• Communication

• Active dialog with owner and authorities• Cultivate dialogue with staff• Public exposure

• Building reporting culture/trust• Sharing lessons learned -> good

leadership behaviour.

What does Safety Culture Give You?

• More competent organisation• Understanding the overall

system• Improved reporting

• Best possible risk-picture• Improved decision making• Safer operations

• A good Safety Culture often influence a good overall business culture.

Occurence Reports vs Serious Incidents

0

500

1000

1500

2000

2500

Y2001 Y2002 Y2003 Y2004 Y2005 Y2006 Y2007 Y2008 Y2009 Y2010

0

2

4

6

8

10

12

Reports

Serious Incidents

* New classification scheme in 2005

*

ReportJust Culture

StatisticsMOR

eSystem

ProceduresVs Practices

Analysis(HERA & Trend)

Causal FactorsRisk Areas

Operational SafetyImprovement

Management & Regulatoryoversight

Safety Improvement Process

No Need to be a Safety Superman

• Walk the talk• Communicate on all levels• Involve Be visible.

Seven practical tips from Safety Directors

• Put safety first on the weekly meeting agenda• CEO needs have a direct report from safety• Know your top five risks and what is being done

about them• Involve safety at the start of projects• Ask how your other directors are doing on the SMS• Ensure Safety / Ops / Eng work well together, with

support from HR & other directorates• Understand your safety culture strengths and

weaknesses

Safety Intelligence Exercise

• We want CEOs to be smarter about safety• But are we smart about it ourselves?

• We want them to ask the right questions• But do we know the answers?

Human Factors ‘Intelligence’ Scenario• A new Centre is getting close to operation. The team of

operators/controllers testing it have identified a number of HF inadequacies: legibility issues, colour coding inconsistencies, non-intuitive displays and controls. Retrofit will cause a six month delay and add 20 million SEK to the project. Unions have got involved and say their members won’t operate the system. There is political pressure to get it operational, and money is tight. The new centre will give the company a competitive advantage.

• What do you do/ask/propose?• As CEO? As HF Manager?• What are the winning / losing arguments?

WORKSHOP – 45 mins

• Small Groups – 4 groups plus one non-HF group (with Barry) – temporary promotion to the ‘Board’

• Discuss what should be done• Consider how to present it to the CEO• What are the best arguments/messages?• What should a CEO know about Human Factors?• Elect a spokesperson to present it to the ‘Board’

Showtime…

Winning arguments…?

Challenges

• What is your proof that this is going to be a real problem? Controllers can adapt.

• Is this a ‘comfort factor’ or a real safety threat?• Would you prefer we lose our competitive advantage and

risk having to reduce staff in 12 months time?• Why didn’t you sort this out earlier?• Denmark are implementing the same system, they’re not

delaying theirs…• Do you have the capability (staff) to do these changes? How

long will it take?

Rabbit punches…

• (Dir. Ops) The supplier conforms with EU Regs on Ergonomics

• We asked an independent consultant and he said the system wasn’t great but was okay.

• I spoke with the leader of the unions. For certain changes in terms and conditions (overtime payments and allowances), they will accept the new system

Remember – the CEO will decide

How you accept defeat can determine your chances of success next time

Why bother with Safety Culture?

Find your real risks, stay open for business

Find out what peoplereally think about

safety

Some think of it as a manager’s insurance policy