Understanding Safety Culture in ATM Rachael Gordon EUROCONTROL - - PowerPoint PPT Presentation

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Understanding Safety Culture in ATM Rachael Gordon EUROCONTROL Experimental Centre

Barry Kirwan - EEC Richard Kennedy - Boeing R&T Claus Lund Jensen – Integra Consultants

EUROCONTROL Safety R&D Seminar

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Talk Content

Current Work Initial SC Survey Conclusions Initial SC Survey Results Initial SC Survey Method Objectives Of SC Survey Why Safety Culture in ATM?

OUTCOMES of 2005 Survey Simplified SC Model 13 SC Elements 100’s of SC Enablers & Disablers

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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

Safe ANSP Safe ANSP

Safety management system ‘competence’ Safety culture ‘commitment’

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Model of Safety Culture

VISIBLE BEHAVIOUR (what management/ ATCOs do) ESPOUSED VALUES (what is said) BASIC ASSUMPTIONS (what is believed) Adapted from Schein (1992)

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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

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Organisational layers

National Regional Organisational Divisional Team National Regional Organisational Divisional Team

Management Supervisors Operations Technicians ACC Level:

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Survey Approach

FOUR ANSPs dispersed around Europe

53 Participants Controllers Supervisors Managers Technicians

Individual Interviews & Group Discussions

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Data Collection

Interview Structure

■ Policy ■ Planning ■ Safety Organisation ■ Regulation & Standards ■ Safety Assessment ■ Safety Surveys ■ Training & Competence ■ Infrastructure & External Services ■ Safety Documents ■ Operations & Work Controls ■ Safety Occurrence Reports ■ Reward / Incentive Systems

Probing Questions

• Are competencies obtained

and maintained to an appropriate level?

• What type of safety training

is undertaken?

• Do you feel that awareness
• f safety stems from

education or the

• rganisation or both?
• Explore whether the
• rganisation invests

sufficient resources in safety training

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Data Analysis

Identified phrases with safety culture relevance Identified phrases with safety culture relevance Identified stories that came from management and operations Identified stories that came from management and operations Categorised phrases according to SC themes Categorised phrases according to SC themes Safety Culture ‘enablers’ & ‘disablers’ Safety Culture ‘enablers’ & ‘disablers’ Examples illustrated in a Safety Culture Model Examples illustrated in a Safety Culture Model

b. a.

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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

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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)

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Safety Culture Elements

Regulator effectiveness Real working practices Trust within an organisation Communication about system / procedure changes Blame & error tolerance Learning from incidents Reporting incidents / communicating problems Theme 3. How we learn for safety Teaming for safety Management involvement in safety Involving ATCOs in safety Theme 2. How we are involved in safety Responsibility for safety Resources for safety Management/ controller commitment Theme 1. How we prioritise for safety

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Simplified Safety Culture Model What is believed What is believed What is said What is said What is done What is done OUTCOME OUTCOME

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Example of poor safety culture What is believed What is believed What is said What is said What is done What is done OUTCOME OUTCOME

Management: say that controllers should not be punished for mistakes Management believe that mistakes are avoidable

Management View Management View

Management: give controllers retraining Controllers believe that management say what they are supposed to say

Controllers View

Controllers: feel that they are punished for their mistakes

• Mistrust in management
• Under-reporting of incidents
• No search for systemic

problems, trends

• No detection of trends
• No organisational learning

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Example of a good safety culture

What is believed

Management and Controllers believe they should submit reports of all

• ccurrence and that human errors exist

and reports are important for learning and improving safety

What is done

Management do not punish those who report, instead they are supported

Outcome

Controllers and Management trust each other and a just culture where

• ccurrences are reported exist

What is said

Management say that controllers should not be punished for their mistakes

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Measuring Safety Climate

Taking a snap-shot

• f the safety culture
• n the day

(by questionnaire)

Measuring Safety Culture

More in-depth understanding of the safety culture (by interviews) Identify main vulnerabilities Further define the causes of the vulnerabilities

Solving Safety Culture

Finding ways to solve these issues (by group discussion)

Guidance

Understanding how

• ther ANSPs have

dealt with this issue (document) Identify some initial solutions within the ANSP Examples of best practice & solutions from other ANSPs

MEASUREMENT GUIDANCE

Study – 2006 – Approach

Development of Measurement & Guidance