EUROCONTROL Safety R&D Seminar Understanding Safety Culture in ATM Rachael Gordon EUROCONTROL Experimental Centre Barry Kirwan - EEC Richard Kennedy - Boeing R&T Claus Lund Jensen – Integra Consultants Safety R&D Seminar Page 1 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Talk Content Why Safety Objectives Culture Of SC in ATM? Survey OUTCOMES of 2005 Survey Simplified SC Model Initial SC 13 SC Elements Current Survey 100’s of SC Enablers Work Method & Disablers Initial SC Initial SC Survey Survey Conclusions Results Safety R&D Seminar Page 2 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Why study Safety Culture in ATM? ■ ATM is a very safe industry … so why is there a need to understand the safety culture? ● Increase in air traffic - could degrade safety if systems are not robust enough ● Formal SMS are currently being implemented, need to ensure the commitment Safety Safety culture management system ‘competence’ ‘commitment’ Safe ANSP Safe ANSP Safety R&D Seminar Page 3 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Model of Safety Culture VISIBLE BEHAVIOUR (what management/ ATCOs do ) ESPOUSED VALUES (what is said ) BASIC ASSUMPTIONS (what is believed ) Adapted from Schein (1992) Safety R&D Seminar Page 4 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Objectives of 2005 Survey ■ Study I – 2005 ● What is safety culture in ATM – what are the elements? ● Do we need a safety culture approach in ATM? ● Develop links between SC and SMS ● Developing a structure for measurement & guidance Safety R&D Seminar Page 5 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Organisational layers ACC Level: Management Supervisors Operations Technicians Team Team Divisional Divisional Organisational Organisational National National Regional Regional Safety R&D Seminar Page 6 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Survey Approach FOUR ANSPs dispersed around Europe 53 Participants Controllers Supervisors Managers Technicians Individual Interviews & Group Discussions Safety R&D Seminar Page 7 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Data Collection Interview Structure Probing Questions Policy • Are competencies obtained ■ and maintained to an Planning ■ appropriate level? Safety Organisation ■ Regulation & Standards ■ • What type of safety training is undertaken? Safety Assessment ■ Safety Surveys ■ • Do you feel that awareness Training & Competence ■ of safety stems from Infrastructure & External Services education or the ■ organisation or both? Safety Documents ■ Operations & Work Controls ■ • Explore whether the Safety Occurrence Reports organisation invests ■ sufficient resources in Reward / Incentive Systems ■ safety training Safety R&D Seminar Page 8 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Data Analysis Identified phrases with a. Identified phrases with Safety Culture ‘enablers’ & Safety Culture ‘enablers’ & safety culture relevance safety culture relevance ‘disablers’ ‘disablers’ Categorised phrases Categorised phrases according to SC themes according to SC themes Identified stories that Identified stories that b. Examples illustrated in a Examples illustrated in a came from management came from management Safety Culture Model and operations Safety Culture Model and operations Safety R&D Seminar Page 9 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Results ■ 100’s of safety culture ‘enablers’ and ‘disablers’ ● Statements from participants of where safety is working and where it is not ● Is being used to develop the questionnaire statements ■ 13 Safety Culture Elements (3 Main Themes) ● Is being used to structure the questionnaire ■ Safety culture stories ● Is being used to develop safety culture guidance ■ Simplified model of safety culture Safety R&D Seminar Page 10 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Safety Culture Enablers & Disablers Prioritise ● Management belief that controllers think too much about safety now and forget efficiency ● Chief of operations discusses safety and writes about it in newsletter; uses “better safe than sorry” motto Responsibilities ● There is no separate safety department – you have to discuss a safety issue with management ● Everyone feels personal responsibility for safety (controllers, management, supervision) - zero LOS is a realistic personal goal Learn ● New procedures communicated in a file of papers you read them when you come to work ● Changes in new procedures / systems are communicated through key people (well respected) Safety R&D Seminar Page 11 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Safety Culture Elements Theme 1. How we Management/ controller commitment prioritise for safety Resources for safety Responsibility for safety Theme 2. How we are Involving ATCOs in safety involved in safety Management involvement in safety Teaming for safety Theme 3. How we learn Reporting incidents / communicating problems for safety Learning from incidents Blame & error tolerance Communication about system / procedure changes Trust within an organisation Real working practices Regulator effectiveness Safety R&D Seminar Page 12 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Simplified Safety Culture Model What is believed What is believed What is done What is said What is done What is said OUTCOME OUTCOME Safety R&D Seminar Page 13 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Example of poor safety culture Controllers View Management View Management View Controllers believe that Management believe that What is believed What is believed management say what they mistakes are avoidable are supposed to say Management: say that controllers should not be What is said What is said punished for mistakes Management: give Controllers: feel that they What is done What is done controllers retraining are punished for their mistakes • No search for systemic • Mistrust in management OUTCOME problems, trends OUTCOME • Under-reporting of incidents • No detection of trends • No organisational learning Safety R&D Seminar Page 14 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Example of a good safety culture What is believed Management and Controllers believe they should submit reports of all occurrence and that human errors exist and reports are important for learning and improving safety What is said What is done Management say that controllers Management do not punish those who should not be punished for their report, instead they are supported mistakes Outcome Controllers and Management trust each other and a just culture where occurrences are reported exist Safety R&D Seminar Page 15 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
Study – 2006 – Approach Development of Measurement & Guidance MEASUREMENT GUIDANCE Measuring Measuring Solving Safety Guidance Safety Climate Culture Safety Culture Understanding how Taking a snap-shot other ANSPs have More in-depth Finding ways to of the safety culture dealt with this issue understanding of solve these issues (document) on the day (by group the safety culture (by questionnaire) (by interviews) discussion) Further define the Identify main Identify some Examples of best causes of the vulnerabilities initial solutions practice & solutions vulnerabilities within the ANSP from other ANSPs Safety R&D Seminar Page 16 / Total_number 25-27 October 2006 EUROCONTROL Barcelona - SPAIN
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