WHERE SAFETY COMES FIRST ! Safety Culture What it is and the Six steps Necessary to Achieve it Presented by Gordon Dupont Presented at Flight Safety Foundation

WHERE SAFETY COMES FIRST !

Safety CultureWhat it is and

the Six steps Necessary to Achieve it

Presented byGordon Dupont

Presented atFlight Safety Foundation Business Aviation Safety SummitMontreal, PQ April 11, 2013

Safety CultureIs a lot more than a sign

Safety FirstUnless it costs money

Unless it costs money

Unless it costs money

it costs moneyit costs money

What is Safety?• The state of being Safe

• The condition of being Safe from undergoing or causing hurt, injury or loss

Webster’s Dictionary

• The risk (odds) of something causing you grief is AAs LLow AAs RReasonably PPractical (ALARP)

G.

Dupont

What is a Safety Culture?

SafetySafety is treated seriously by the management and all employeesSafetySafety goals are set and all work toward their achievementallall company employees are trained and encouraged to think and

work SafelySafely at all timesa system is in place to report SafetySafety concernsallall believe that SafetySafety does not have to come at the cost of

productivity or profitSafetySafety is an integral part of the way the company operatesThe company has a framework to accomplish all of the above –

A SafetySafety Management System (SMS)

Gordon Dupont

It is a Culture where:

Why is a Safety Culture so important now?

The probability (risk) of being killed in an aircraft accident varies from

1 in 260,000 (Africa)

To

1 in 11,000,000 (45 million 2012 USA)

A difference of 42 times better Why?

A Safety Culture makes a differenceA Safety Culture makes a difference

Hull loss accident rate

Airline Aircraft in service

12,595

1997

Millions of departures

Hull loss accidentsper year

1965 1975 1985 1995 2005 2015

Year

50

45

40

35

30

25

20

15

10

5

0

Boeing Aircraft Corporation

25,598

2016

Business

as usu

al

With HF TrainingAnd a Safety ManagementSystem

Major Fatal Airline Accidents per year

By 2016 there will be one major fatal accident per week somewhere in the world

We must We must continue to continue to do betterdo better

You’ll Know it When You’ll Know it When You Work in itYou Work in it

• It is very difficult to measure accurately

• It is seen by the way things are done around the organization

• It is heavily influenced by management

• It is constantly changing

What does a Safety Culture look like?

A Safety Culture must have the 3 “C’s”

C

C

C

ommitment

ompetence

ognizance

Mintzberg

Management’s True motivation and allocation of resources

Knowledge to know how to achieve the organization’s Safety goals

Awareness that it is a never ending battle

The Six Steps to a Safety Culture

1. 1. JUSTJUST cultureJames ReasonGordon Dupont

Step 1 A JustJust Culture

• A Just Culture is the foundation of any Safety Culture

• Where “Honest & At-RiskHonest & At-Risk” mistakes do not result in discipline

• Where an Administrative policy spells out “Reckless Behaviour”“Reckless Behaviour”

• Where persons can admit to an error without fear of punishment

Screw up and you’re history

But what about Discipline?• What is the realreal purpose of

discipline? Only the Mafia with

their cement boots

have a harsher

discipline policy

Giselle Richardson

TO BE SEEN TO BE DOING SOMETHING?

TRADITION?

To ensure an To ensure an occurrence occurrence does does notnot happen again happen again

• REVENGE?REVENGE?

Holding the Person AccountableHolding the Person Accountable

If only they all wore hats

Was the act deliberate with a reasonable knowledge of the possible consequences? Has the person made similar errors in the past?

Do they accept responsibility for their actions?

Degree of DisciplineDegree of DisciplineXX

XX

XX



Has the person learned from the experience?

Are they likely to do it again?


XX

XX

XX

XX

Anyone can make a mistake

but

only a fool (company or individual)

makes the

same mistake twice



Has the person learned from the experience?

Are they likely to do it again?


XX

XX

XX

XX

Remember the reason for DisciplineRemember the reason for Discipline

To Ensure It Does Not Happen AgainTo Ensure It Does Not Happen Again

Discipline – To Ensure That It Does Not Happen Again

• No hull insuranceNo hull insurance• Wife severely injuredWife severely injured• Pilot severely injuredPilot severely injured• Off work for a monthOff work for a month

He was foundHe was foundNOT GUILTYNOT GUILTY

James ReasonGordon Dupont

1. 1. JUSTJUST culture

SAFETYSAFETY culture

2. TRUSTING culture (G. Dupont)

Levels of Trust

Low

High

HighCooperationCooperation

TrustTrustDefensive – Us vs. Them Defensive – Us vs. Them (Lose Lose)

Respectful - CompromiseRespectful - Compromise (Win Lose – Lose Win)

Synergistic - WE can solve the problem (Win Win)

Step 2 A Trusting Trusting Culture

James ReasonGordon Dupont1. 1. JUSTJUST culture

3. REPORTING culture



provides the means to capture the lessons to be learned arising from

human errors, near misses or free lessons

Step 3 Step 3 AA ReportingReporting Culture

You can’t fix what you don’t know

•Interview Responsible Interview Responsible Personnel Personnel•• Find Contributing Find Contributing FactorsFactors•• Get Ideas for Process Get Ideas for Process

ImprovementImprovement

MEDA MEDA (Maintenance Error Decision Aid) Objectives Objectives

EventEventOccursOccurs

•• Many Current Error Investigation ProcessesMany Current Error Investigation ProcessesInvestigation Investigation Reveals Event Reveals Event

Caused by Caused by Maintenance Maintenance

ErrorError

Determine Determine Who Made Who Made

ErrorErrorAdministerAdministerDisciplineDiscipline

EventEventOccursOccurs

•• The MEDA ProcessThe MEDA Process

Investigation Investigation Reveals Event Reveals Event

Caused by Caused by Maintenance Maintenance

ErrorError

Determine Determine Who Made Who Made

ErrorError

Follow-up to Follow-up to Obtain Obtain

Additional Additional Contributing Contributing Factors and Factors and InformationInformation

Add to Add to Maintenance Maintenance Error Data Error Data

BaseBase

Make Process Improvements Make Process Improvements Based on Contributing FactorsBased on Contributing Factors

•• Based on This EventBased on This Event•• Based on Analysis of Data Based on Analysis of Data

for Multiple Eventsfor Multiple Events

Provide Feedback Provide Feedback to All Employees to All Employees Affected by Affected by Process Process ImprovementsImprovements

Don’t Sweat the Small StuffSmall Stuff

And You Will Avoid Having to

Sweat the Big StuffBig Stuff

This is what SMS is all about

The Small StuffSmall Stuff has the potential to become the Big StuffBig Stuff

Gordon Dupont

For Example


4. LEARNING culture




Enables us to take the reports with their “Free lessons” and through Risk ManagementRisk Management lower the hazards that

threaten the Safety of the organization

Enables us to analyze what we weren’t even aware of before

We are able to fix the problem (Hazard) before it causes an accident

Takes us from the ReactiveReactive level to the ProactiveProactive level

Step 4. A LearningLearning Culture

Step 4 A LearningLearning Culture

• Where human factors training is provided to allall on an ongoing basis

• Where incident data is kept and analyzed to find trends and develop Safety nets

• Where major changes are carried out when the present system is not sufficiently Safe

• Where feedback is provided as a means of learning from all incidents


5. INFORMED culture

4. LEARNING culture




Step 5 An InformedInformed Culture

1. A Mission Statement - Posted

Where everyone knows the organization’s true SafetySafety commitment

A Mission StatementThat Everyone Knows


1. A Mission Statement - Posted

2. A Safety Policy - Posted


ManagementManagers and supervisors

Managers and supervisorsSupervisorsSupervisory

EmployeeEmployee

Everyone

This is an excellent one


3. An Administrative Policy – Known by all

4. Long term Safety goals – Known by all who work toward them

5. Optional - Core Values Statement - Posted


1.A Mission Statement - Posted

2.A Safety Policy - Posted


5. INFORMED culture

4. LEARNING culture




6. FLEXIBLE culture

Step 6 A FlexibleFlexible Culture

• Where necessary changes are made in order to improve Safety

• Where the organization is constantly looking for better ways to work Safer

• Where the status quo is not considered an option in the quest to lower errors

• Where there is a “Chronic Unease”“Chronic Unease” that in spite of all efforts, human error will still occur

• Where an EEmergency RResponse PPlan (ERP) is in place in the event of an error occurring


5. INFORMED culture

4. LEARNING culture




6. FLEXIBLE cultureYo

u no

w

have

a S

afet

y

cultur

e th

at

is A

LARP

Thank You for the Opportunity to Provide this Message

Gordon Dupont

What Class of Error?

Honest, Honest, At-Risk, RecklessReckless

How do we measure this?

Documents

WHERE SAFETY COMES FIRST ! Safety Culture What it is and the Six steps Necessary to Achieve it Presented by Gordon Dupont Presented at Flight Safety Foundation