Achieving a Safety Culture

ANN
 Safety Management Systems
• Safety Management Systems
are about operating with a
systematic approach
• The hazards are identified
• The controls are in place
• Assurance can be provided
with a Safety Case
 Analysis
Immediate causes
• Violations by individuals
and supervisors
• Lack of knowledge of
hazards present
• Poor decision making
• Seen as routine activities
• Defective safety devices
• Inadequate equipment
Cultural issues
• Poorly motivated workforce,
behaved in a disempowered way
• Lack of enforcement of following
procedures
• Lack of role models at supervisor
and superintendent levels
• Little expectation of behaviours
and performance
• No consequences of good or bad
performance
• Fear to challenge and say “no”
• Lack of teamwork evidenced by
many behaviours and attitudes
 A study
Ideal
- Management where I work listens to
my ideas for improvement
- My line manager/team leader treats
me fairly
- My line manager/team leader would
support me if I needed help in handling
tensions between my work and personal
life
- My pay is linked to my performance
Actual -
•I am satisfied with my involvement in
decisions that affect my work
•Where I work, we are treated with
respect
•My team leader coaches me
effectively
•My team leader supports me in
balancing my work and my personal life
•I believe what leaders in my
organisation say
•I get a clear sense of my
organisation's direction from my
leadership team
Culture is a basic issue in all these
accidents
• Our culture determines what we regard as
important

• Our culture determines what we see as

normal and acceptable

• Culture acts as a multiplier on all safety

elements
– Plant - equipment
– Process
– People
 Safety Culture
The Added Ingredient
• Safety Management Systems and Safety Cases
provide a systematic approach to safety
• Safety Management systems are still driven by paper
• 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
 Improvements in Safety
Performance
Technology

Systems
Numbers of Incidents

• Behaviours
• Engineering • Leadership
• Equipment • Accountability
• Safety • Attitudes
• Compliance • HSE as a profit centre

• Integrating Culture
HSE
• Certification
• Competence
• Risk
Assessment

Time
 Characteristics of a Safety
Culture
• Informed - Managers know what is really
going on and workforce is willing to report
their own errors and near misses
• Wary - ready for the unexpected
• Just - a ‘no blame’ culture, with a clear line
between the acceptable and unacceptable
• Flexible - operates according to need
• Learning - willing to adapt and implement
necessary reforms
 The HSSE Culture Ladder
GENERATIVE (HRO)
HSE is how we do business
round here

PROACTIVE
ed Safety leadership and values
rm
drive continuous improvement
fo

y
lit
In

bi
CALCULATIVE
y

ta
We have systems in place to
gl

un
sin

manage all hazards

co
ea

Ac
cr

REACTIVE

d
In

Safety is important, we do a lot

an
every time we have an accident

t
us
Tr
PATHOLOGICAL

g
in
Who cares as long as

s
we're not caught

ea
cr
In
 So what does a
Generative culture
look like?

The High Reliability

Organisation (HRO)
 The Generative Organization
• Low profile - always to be relied on
• Low accident rate - but there is always bad luck
• Active involvement and accountability for all
• Workforce initiative in safety and operations
• Short and effective feedback lines
• Procedures under constant scrutiny
• Training, cross-training and more training
• Benchmarking against others, inside and out
• Obsessive planning - many scenarios create requisite variety
• Willing to try new ideas, but accept the risk of failures
• Chronic Unease

• Can be equated with the High Reliability Organisation (HRO)

Safety cultures allow taking risks
Taking risks makes money
• Safety management can only manage
standard hazards
• Safety cultures take more account of
the hazards and ways of living safely
• This enables them to operate closer to
the edge
• Return on capital is a function of risks
taken
• Safety cultures are not reckless
• This is the advantage
 The Edge
The Edge

Normally Safe

No need Inherently
Safe Return on
6% Capital
9%
12% Invested
Normally Safe

Safety Management Systems The Edge

Safety Culture
 How to create a Safety Culture
• Depends on where you are starting from -
you don’t get to the end in one step,
unfortunately, all the steps have to be
traversed
• Becoming a Safety Culture involves acquiring
and then maintaining a set of skills
• The two major factors are informedness and
trust, so these have to be developed
• Be systematic (Safety Management Systems
are a start) and then learn to operate with
the unknown as well
 Creating a Safety Culture II
• Have the program run right from the
top - It’s the CEO’s pet project
• Appoint a senior champion who is
dedicated and willing to stick it out,
even when it gets hard
• The champion reports direct to the
CEO and the board
• Recognise that it will be
uncomfortable, safety cultures are
different, not just an add-on
 Which drivers for which culture?
• Pathological respond to regulation
– They don’t know the rest or it won’t happen anyway
– They may be shifted if they are confronted with the costs
• Reactive respond to ethics, laws, regulation and
accident costs (everything!)
• Calculative respond to regulation
– They may be ethical but regulations and systems are they way
they succeed
• Proactive respond to costs (as lost benefits)
– Regulations are seen as defining minimum requirements
• Generative respond to benefits and self-image
– They see it as strange if you don’t have HSE as a priority
 Developing a Safety Culture:
Informed and Learning
• Agree on ways to analyse incidents to reveal
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 all incidents are worth reporting
• Experiment with changes when new information
comes in, don’t be afraid to admit failure first
time round
• Practice management in wanting to know from
near misses before they become accidents
 Developing a Safety Culture:
Just
• Get rid of the idea that blame is a
useful concept (this is hard to do)
• Define clear lines between the
acceptable and the unacceptable
• Have those involved draw up the
guidelines, do not impose from above
if you want them to be accepted
• Have clear procedures about what to
do with other forms of non-compliance
 Developing a Safety Culture:
Wary
• Most dangerous situations can be planned for
• Planning is never a bad thing, but
• Your remaining problems arise from what you
never thought of or considered, so:
– Construct systems that can cope with the unexpected
– Practice Chronic Unease
• Chronic Unease means moving from
– “We haven’t had an accident, aren’t we doing well” to
– “We haven’t had an accident, what are we overlooking?
life isn’t that fair”
 Developing a Safety Culture:
Flexible
• Develop a workforce that is more than ‘just’
competent - multi-skilling is easier or even
necessary in smaller airlines
• Move control down as far as possible
• Develop the possibilities for ‘variance
procedures’ where operations are defined by
what is safe and sensible
– Risk assessment of ongoing activities
– Competence defined limits on freedom to act
– Lots of communication when there are
differences
 Maintaining a Safety Culture
• The greatest enemy is success - complacency
is easy
– If you find yourself saying “Now we can get back
to the real business” you have lost it
• Keep maintenance as a target in its own right
• Keep close to the hazards
– The most effective way to stay awake is to stay
scared
– If you can’t find your own accidents, go find
someone else’s
• Never let up
 Challenges to Safety Culture

• The overall culture itself is a

source of problems
• Regulators can create legal
barriers if their own culture is
less advanced
• Management can lose their nerve
and promote the champions away
• Change is hard and the status
quo comfortable
 Why Don’t They?
• Organisational cultures are only capable of
understanding the world in ways appropriate
to their current safety culture level and their
readiness to change
– Less advanced cultures just don’t
understand that it’s better up there!
• Counter-pressures exist to force organisations
back towards the Calculative
• The Generative represents a vast leap into
the unknown
 Conclusion
• Safe organisations make money
where others do not dare to
operate
• Safety cultures have increased trust
(and lower costs)
–From management to workforce
–From workforce to management