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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 one sees it. Does he report it?

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

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

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The Safety Culture Process

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

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

Results of a Safety Culture Survey at

XXXXXVersion: 1.0

Date: 3 June 2011

Confidential

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The Process – High Level

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

• Strengths• Areas for improvement

Give feedback to participants Build on the Results

Prepare

Launch

Run

Learn

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Step 1. Prepare (1/2)

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

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

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

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

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

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

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Step 1. Prepare (2/2)

Select Approach• Questionnaire; focus groups

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

Select Outside Agency• Eurocontrol; Consultancy; University

Determine Launch Date• Best if not during summer period

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Step 2. Launch

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

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. St

rong

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isag

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Dis

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Nei

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Stro

ngly

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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

ControllersEngineers

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) + Facilitators

Key issues• Ensure understanding• Consider causes and

consequences

Potential solution paths Key ways forward Mode: 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 priorities• Strategic – e.g. safety culture campaigns• Tactical – e.g. improve computerised incident

reporting system

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

change culture Track & Monitor Progress Communicate, communicate, communicate

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Timescale of the Survey Process

0 1m 3m 6m 1yr 3 years

Launch

Analysis

Focus groups

ImprovementStrategy

Mid-termReview

Strategic review2nd 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 &

ResponsibilityLearning and Trust

Example ‘Board Level’ Picture

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Example Recommendations

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

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

Deal with certain safety ‘hotspots’ identified in the survey

Review OJTI training protocols in high intensity work situations

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

Evaluate extent of ‘workarounds’ Gain more operational involvement

in HAZOPs etc. Clarify safety responsibilities for all

staff including corporate management

Prioritise safety resources Renew Team Resource

Management

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Way ahead – ANSP ownership

Company Action Plan Monitor Progress at Board

Level Aim to Improve within 3 years

Feedback

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Support

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

Toolbox Technical 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 Support• EUROCONTROL, CANSO and FAA all

have placed Safety Culture as a strategic objective over the next 5 years.

Peer Support• EUROCONTROL planning ANSP regional

workshops in 2009 onwards

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Summary

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

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

Questions?

Safety

Costs