A Shift In

“Safety Thinking”

Presented by: Jim Hein, ASI-FPM-MAS

Presented to: NBAA IA Renewal

October 21, 2013

Human Behavior

Safety Management

Series

Zero Violations is the “new standard”

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Reasons for this presentation:

• Promote a generative safety culture.

• Promote a “zero violation” climate

• Promote a “Reporting Culture”

The Safety

Concept

Human Behavior

Safety Management

Series

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Concept of safety

• What is safety

– Zero accidents (or serious incidents)?

– Freedom from danger or risks?

– Error avoidance

– Regulatory compliance?

– … ?

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Concept of safety

• Safety is the state in which the risk of harm to

persons or property damage is reduced to, and

maintained at or below, an acceptable level through

a continuing process of hazard identification, risk

management and use of established safety

controls.

Ref: ICAO Doc 9859

reduced to

an acceptable level through

use of established safety

controls.

Safety is risk

Risk level

Acceptable risk level

Established safety controls

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Concept of safety

Ref: ICAO Doc 9859

Risk level

Acceptable risk level

Established safety controls

• Combination of hazard consequences and frequency

• Risk level is unknown until hazards are analyzed

• Level established by the organization

• Done by a documented methodical process

• Policies, procedures, regulations, best practices …

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Controls are mitigation

strategies designed to reduce

risk when “human factors”

negatively combine with what

we are doing.

• Policies

• Procedures

• Rules

• Regulations

• Best Practices

History of

“Safety-Think”

Human Behavior

Safety Management

Series

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The evolution of safety thinking

TODAY 1950s TECHNICAL

FACTORS

1970s HUMAN

FACTORS TODAY

1990s ORGANIZATIONAL

FACTORS TODAY

2000s CULTURAL

FACTORS TODAY

Manufacturing, Operations, Maintenance, Design

Human Failures

Management, supervision, company policies

Behavioral Failures

Culture

Traits

Human Behavior

Safety Management

Series

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Distinct culture sources • National culture encompasses the value system of

particular nations.

• Organizational/corporate culture differentiates the

values and behaviours of particular organizations

(e.g. government vs. private organizations).

• Professional culture differentiates the values and

behaviours of particular professional groups (e.g.

pilots, air traffic controllers, maintenance

engineers, aerodrome staff, etc.).

• Personal culture …. Differentiates the values and

behaviours of each individual for any given

circumstance.

No human endeavour is culture-free

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Organizational/corporate culture

• Sets the boundaries for acceptable behaviour in the

workplace by establishing limits.

• Establishes acceptable risk levels.

• Provides a frame work for managerial and

employee decision-making

• Shapes acceptable procedures and practices.

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Organizational Culture Attributes:

Hidden

Shouted

Shirked

Discouraged

Covered up

Crushed

Conflicted organization

Ignored

Tolerated

Boxed

Allowed

Merciful

Problematic

“Red tape” organization

Sought

Trained

Shared

Rewarded

Scrutinized

Welcomed

Reliable organization

Pathological Bureaucratic Generative

Information

Messengers

Responsibilities

Reports

Failures

New ideas

Resulting organization

Source: Ron Westrum

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PATHOLOGICAL who cares as long as we’re not caught

REACTIVE Safety is important, we do a lot every

time we have an accident

CALCULATIVE we have systems in place to manage

all hazards

PROACTIVE we work on the problems that we still

find

GENERATIVE safety is how we do business

round here

Increasing Trust

Increasingly

informed

Range of organizational cultures

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Culture Summary

• National

• Organizational

• Professional

• Personal

• Pathological

• Bureaucratic

• Proactive

• Generative

CULTURE TYPES CULTURE TRAITS

• Just

• Flexible

• Willing

GENERATIVE CULTURE TRAITS

• Learning

• Accountable

• Reporting

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Personal culture

• Must comply with the limits established for

acceptable behaviour in the workplace.

• Must protect acceptable risk levels.

• Must believe in, support and utilize safety reporting

procedures and practices set by the Organizational

culture.

• Can highly influence behaviours within the

organizational culture (positively and negatively).

Errors Mistakes

and Lapses

Human Behavior

Safety Management

Series

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Understanding human error

• Competent people commit errors.

• Errors are normal where humans and

technology interact.

• Human error is a contributing finding in

aviation occurrence investigations.

• Risk reduction strategies protect when

human errors occur.

Controls are mitigation strategies designed to reduce risk when

“human factors” negatively combine with what we are doing.

“Violations”

vs

“Mistakes”

Human Behavior

Safety Management

Series

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Violation Definition

• Violations are deliberate and intentional deviations from policies, rules, procedures, instructions, regulations, and best practices developed to promote acceptable risk levels and efficient operations.

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Violation Definition

• This should not be confused with the human condition of making mistakes.

• Human errors, mistakes and violations all result in “non-compliance”

• The difference is that

violations are preventable.

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Understanding violations:

System output Maximum Minimum

Risk

High

Low

Safety space

Vio

lati

on

sp

ace

Exc

epti

on

al v

iola

tio

n s

pac

e

Incident

Accident

System’s production objective(s)

Acceptable

risk level

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Rationalizations for Violation

• Expectation – Rule must be bent to get the job done

• Powerfulness – Ability, Experience, Judgement

• Opportunities – Optimization, Short cuts, Better, Quicker

• Planning – Poor advance preparation, working on the fly

Patrick T.W. Hudson, D. Parker, R. Lawton, (2005)

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Why are Violations Dangerous?

• Violators assume they’re the only one

• Violators don’t tell anyone what they are doing

• Violations Increase risk levels to “unacceptable”

• Errors (slips, lapses, mistakes) are independent

of intention

• Violations combine with human errors to create

unacceptable or dangerous circumstances.

• Violation + Error = Death/Doom/Disaster

Managing Maintenance Error, James Reasons and Alan Hobbs

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Tools for better

safety cultures

Human Behavior

Safety Management

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Tools currently available

• Management Training

• SMS Training (SRM- SA)

• Root Cause Analysis Training

• LOSA

• HF Training

• Employee Reporting

Effective safety reporting – Five traits

Information

People are knowledgeable about the human, technical and

organizational factors that determine the safety of the system

as a whole.

Flexibility People can adapt reporting

when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing

information to quickly reach the appropriate decision-

making level .

Learning

People have the competence

to draw conclusions from

safety information systems

and the will to implement

major reforms.

Willingness

People are willing to

report their errors and

experiences.

Accountability

People are encouraged (and rewarded) for providing essential

safety-related information. However, there is a clear line that

differentiates between acceptable and unacceptable behaviour.

Effective safety reporting

Barriers to a

Zero Violation

Safety Climate

Human Behavior

Safety Management

Series

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# 1 Barrier to ZV success

• People are afraid of

unknown

• Expectations based on past

experience

• Desire to “test” the system

• Looking for WIIFM

• Fear of losing job

• Fear of being outside of

comfort zone

• Fear of being out of control

• Perceived as a “turf” battle

• Feeling of inadequacy

– Lack of experience

– Lack of sufficient skills

• Lack of management

sponsorship

Resistance and Fear*

* Change Management, Chad Van Zandt, 2004

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Change Resistance Antidotes:

• Training

• Coaching

• Support

• Reinforcement

• Communications

• Set Zero Violations as the minimum

“STANDARD”

* Change Management, Chad Van Zandt, 2004

Call to Action

Human Behavior

Safety Management

Series

Now is the time for a

“safety-think” shift

Begin by making Zero Violations

“The Standard”

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