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Safety Culture What it is and the Six steps Necessary to Achieve it

Safety Culture What it is and the Six steps Necessary to Achieve it. WHERE SAFETY COMES FIRST !. Presented at Flight Safety Foundation Business Aviation Safety Summit Montreal, PQ April 11, 2013. Presented by Gordon Dupont. Safety Culture Is a lot more than a sign. Safety First.

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Safety Culture What it is and the Six steps Necessary to Achieve it

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  1. Safety CultureWhat it is and the Six steps Necessary to Achieve it WHERE SAFETY COMES FIRST ! Presented at Flight Safety Foundation Business Aviation Safety Summit Montreal, PQ April 11, 2013 Presented by Gordon Dupont

  2. Safety CultureIs a lot more than a sign Safety First Unless it costs money Unless it costs money Unless it costs money it costs money

  3. 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 As Low As Reasonably Practical (ALARP) G. Dupont

  4. It is a Culture where: What is a Safety Culture? • Safetyis treated seriously by the management and all employees • Safety goals are set and all work toward their achievement • allcompany employees are trained and encouraged to think and work Safely at all times • a system is in place to report Safety concerns • allbelieve that Safety does not have to come at the cost of productivity or profit • Safety is an integral part of the way the company operates • The company has a framework to accomplish all of the above –A SafetyManagement System (SMS) Gordon Dupont

  5. 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 42times better Why? A Safety Culture makes a difference

  6. Airline Aircraft in service 25,598 12,595 Business as usual 1997 2016 Hull loss accidentsper year With HF Training And a Safety Management System Millions of departures Hull loss accident rate Major Fatal Airline Accidents per year 50 45 40 35 30 25 20 15 10 5 0 We must continue to do better 1965 1975 1985 1995 2005 2015 Year Boeing Aircraft Corporation By 2016 there will be one major fatal accident per week somewhere in the world

  7. What does a Safety Culture look like? You’ll Know it When You 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

  8. A Safety Culture must have the 3 “C’s” C ommitment Management’s True motivation and allocation of resources C ompetence Knowledge to know how to achieve the organization’s Safety goals C ognizance Awareness that it is a never ending battle Mintzberg

  9. The Six Steps to a Safety Culture 1. JUST culture James ReasonGordon Dupont

  10. Step 1 A Just Culture • A Just Culture is the foundation of any Safety Culture • Where “Honest & At-Risk” mistakes do not result in discipline • Where an Administrative policy spells out “Reckless Behaviour” • Where persons can admit to an error without fear of punishment Screw up and you’re history

  11. But what about Discipline? Only the Mafia with their cement boots have a harsher discipline policy Giselle Richardson • What is therealpurpose of discipline? • REVENGE? Holding the Person Accountable TO BE SEEN TO BE DOING SOMETHING? TRADITION? To ensure an occurrence does not happen again

  12. If only they all wore hats Hang OK

  13. Degree of Discipline X • 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? X X

  14. Degree of Discipline X • 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? • Has the person learned from the experience? • Are they likely to do it again? X X X X

  15. Anyone can make a mistake but only a fool (company or individual) makes the same mistake twice

  16. Degree of Discipline X • 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? • Has the person learned from the experience? • Are they likely to do it again? X X X X Remember the reason for Discipline To Ensure It Does Not Happen Again

  17. He was found NOT GUILTY Discipline – To Ensure That It Does Not Happen Again And OUR industry decides to spend thousands of $$$ in order to convict him and fine him $100!!! • No hull insurance • Wife severely injured • Pilot severely injured • Off work for a month

  18. SAFETY culture 2. TRUSTING culture (G. Dupont) James ReasonGordon Dupont 1. JUST culture

  19. Step 2 A Trusting Culture Levels of Trust Synergistic - WE can solve the problem (Win Win) High Respectful - Compromise(Win Lose – Lose Win) Trust Defensive – Us vs. Them (Lose Lose) Low Cooperation High

  20. SAFETY culture 3. REPORTING culture 2. TRUSTING culture (G. Dupont) James ReasonGordon Dupont 1. JUST culture

  21. Step 3 AReporting Culture provides the means to capture the lessons to be learned arising from human errors, near misses or free lessons You can’t fix what you don’t know

  22. MEDA (Maintenance Error Decision Aid) Objectives • Many Current Error Investigation Processes Investigation Reveals Event Caused by Maintenance Error Determine Who Made Error EventOccurs AdministerDiscipline • The MEDA Process Follow-up to Obtain Additional Contributing Factors and Information • Interview Responsible Personnel• Find Contributing • Factors• Get Ideas for Process Improvement Investigation Reveals Event Caused by Maintenance Error Determine Who Made Error EventOccurs Provide Feedback to All Employees Affected by Process Improvements Add to Maintenance Error Data Base Make Process Improvements Based on Contributing Factors • Based on This Event • Based on Analysis of Data for Multiple Events

  23. And You Will Avoid Having to Sweat the Big Stuff Don’t Sweat the Small Stuff Gordon Dupont This is what SMS is all about The Small Stuff has the potential to become the Big Stuff For Example

  24. SAFETY culture 4. LEARNING culture 3. REPORTING culture 2. TRUSTING culture (G. Dupont) 1. JUST culture James ReasonGordon Dupont

  25. Step 4. A Learning Culture Enables us to take the reports with their “Free lessons” and through Risk 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 Reactive level to the Proactive level

  26. Step 4 A Learning Culture • Where human factors training is provided to all 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

  27. SAFETY culture 5. INFORMED culture 4. LEARNING culture 3. REPORTING culture 2. TRUSTING culture (G. Dupont) James ReasonGordon Dupont 1. JUST culture

  28. Step 5 An Informed Culture Where everyone knows the organization’s true Safety commitment • A Mission Statement - Posted

  29. A Mission Statement That Everyone Knows

  30. Step 5 An Informed Culture Where everyone knows the organization’s true Safety commitment • A Mission Statement - Posted • A Safety Policy - Posted

  31. Management Managers and supervisors Managers and supervisors Supervisors Supervisory Employee Employee Everyone

  32. This is an excellent one

  33. Step 5 An Informed Culture Where everyone knows the organization’s true Safety commitment • A Mission Statement - Posted • A Safety Policy - Posted • 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

  34. SAFETY culture 6. FLEXIBLE culture 5. INFORMED culture 4. LEARNING culture 3. REPORTING culture 2. TRUSTING culture (G. Dupont) James ReasonGordon Dupont 1. JUST culture

  35. Step 6 A FlexibleCulture • 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” that in spite of all efforts, human error will still occur • Where an Emergency Response Plan (ERP) is in place in the event of an error occurring

  36. SAFETY culture You now have a Safety culture that is ALARP 6. FLEXIBLE culture 5. INFORMED culture 4. LEARNING culture 3. REPORTING culture 2. TRUSTING culture (G. Dupont) James ReasonGordon Dupont 1. JUST culture

  37. Thank You for the Opportunity to Provide this Message Any Questions? Gordon Dupont

  38. What Class of Error? Honest, At-Risk, Reckless

  39. How do we measure this?

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