developing safety culture

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Developing a safety culture in a research and development environment:

Ai r Traf fi c Management domain.

Europe Chapter of the Human Factors and Ergonomic Society conference, October 27-29, 2004.

Rachael Gordon and Barry Kirwan

EUROCONTROL Experimental Centre

BP 15, Bretigny-sur-Orge, F-91222

FRANCE

Abstract

Measuring safety climate has been undertaken in many industries (e.g. oil, nuclear, aviation) overthe past twenty years, as a proactive method of collecting safety information about the currentlevel of safety in the organisation. However, there has been little work undertaken to develop thesafety culture of the designers of these technological systems, to ensure that their designs areendeavouring to reach the highest levels of safety. A tool was developed to measure the currentlevel of safety culture of designers in an air traffic navigation R&D organisation and contains 21sub-sections under the following four main headings: i) Management Demonstration of Safety; ii)Planning and Organising for Safety; iii) Communication, Trust & Responsibility for Safety and iv)Measuring, Auditing and Reviewing. The findings indicated that the main areas for improvementare: i) the safety management system; ii) team integration; iii) responsibility for safety. Based onthe survey findings some changes were undertaken in an attempt to improve the safety culture atthe centre and a repeat survey is planned for April, 2005 to assess any improvements. This paperwill describe the survey method and findings, the safety improvement plan, preliminary findingsfrom the follow-up survey and lessons learnt during the change process.


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1. INTRODUCTION

Safety culture in ATM operations

ATM is currently seen by other industries as a High Reliability Organisation (HRO), although it is

not fully understood why ATM is so safe. Safety, in the levels seen in ATM, is something of anemergent property, built on the professionalism within the industry, and decades of trial and errorin evolving best practices and procedures. It is obviously desirable that ATM retains this hard-wonHRO status. The most likely way it could lose this characteristic is via fundamental change, i.e.changes at the core of ATM (since and change is one of the main generalised causes ofaccidents). Therefore, it is important that at the development stage of the new systems, safety isconsidered to ensure that such changes will not result in losing the emergent property of safety.

There is an obvious need for good safety culture in operations, where controllers are directlyinvolved in the separation of aircraft. The need for having informed, just, reporting, flexible,learning (Reason, 1997) and wary cultures (Hudson, 2001`) in an operational centre isapparent, however, this requirement is not always obvious to those who are not at the operationalsharp end, such as the developers of new technologies, systems and procedures.

In fact, safety culture has been measured in a number of European Air Navigation ServiceProviders (ANSP) including NATS (UK National Air Traffic Services) and by the Swedish CAA

The need for a good safety culture in R&D

Most ATM organisations collect information about reactive indicators of safety, such as loss ofaircraft separation. However, due to the limited information from such occurrences, it is importantto collect other measures of safety data. One challenge for the EEC is to develop a method whichcan be applied at the research and design stage, in order to identify safety critical issues early on.Safety is an essential aspect of research and design in ATM and therefore it is important that theEEC organisation strives for higher levels of safety awareness, more positive attitudes andcommitment to safety. For this reason, it is appropriate to measure safety culture in the EEC.

Many high reliability industries around the world are showing an interest in the concept of safetyculture, as a way of reducing the potential for large-scale disasters. Organisations have certaincharacteristics which can be called its culture. These are generally invisible to those within thecompany, and yet quite transparent to those from a different culture. Safety culture is a sub-set oforganisational culture which has been described as: who and what we are, what we findimportant, and how we go about doing things around here (Hudson, 2000). Researchers haveshown that organisations with good safety cultures tend to have fewer accidents. But there is littlework on safety culture in research organizations, and what exactly it might mean at a workinglevel in such organizations.

In practical terms, when people are researching and developing new systems, if they areconsidering safety and believe it is important, this will affect how the system is developed inevitably there are many decisions and trade-offs that must be made during early development

and design stages. These are however often too early or too specialized or localized to comeunder formal safety assessment scrutiny. Nevertheless, if there is not a particularly positive andactive safety culture, safety may be the loser during such decisions and trade-offs, especiallywhen safety may seem to be a distant ideal of a system that will not be operational for anotherfive to ten years. Safety can simply be seen to be someone elses problem, or something that canbe fixed later on.

It is important therefore that those working at this design and development end of the operationalspectrum understand safety, and know how their decisions can affect and curtail real safety lateron. This is not an easy process, especially as it can be seen to constrain designer freedom and

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creativity. However, at a practical level, the types of safety thinking that are desirable in aresearch/design organization for a safety critical industry, would appear to be the following:

For the system I am working on, what types of incidents and accidents haveoccurred? How could a new design avoid such problems? Could my new systemadd new problems, alone or in concert with other developments? Could mysystem solve problems in other areas? Will the operator (in this case a controller)be able to deal with events such as system failures, whether revealed orunrevealed, and other anticipatable events? Will the system be robust andsupportive enough that the future operator can deal with future events that Icannot at this point anticipate? Etc.

Such thinking, and resources to support such thinking (e.g. knowledge of incidents and failurepaths etc.), should help generate more safe systems.

2. MEASURING SAFETY CULTURESafety culture (or safety climate) in the workplace has traditionally been measured usingquestionnaire surveys, and has focused on the perceptions and attitudes of the workers. More

recently, organisations safety culture have been measured in terms of their level of maturity,where can be described on a line from emergent to continually improving, from worst to best.The Safety Culture Maturity Model

1(Fleming et al, 1999) was originally designed for the offshore

oil industry, but the structure has been used in other high reliability organisations, including ATMand to measure the level of maturity of safety in design (Sharp et al, 2002) in the offshore oilindustry. The Safety Culture Maturity Model

1contains 5 iterative stages of maturity (see Figure 1),

where organisations can progress sequentially by building on their strengths and removing theweaknesses.

EmergingLevel 1

InvolvingLevel 3

ManagingLevel 2

CooperatingLevel 4

ContinuallyImproving

Level 5

Increa

singc

onsisten

cy

Impro

vingSafet

yCult

ure

Figure 1. The Safety Culture Maturity Model1(from Fleming et al, 1999)

In the early stages of a safety culture (Levels 1 and 2), top management believes accidents to becaused by stupidity, inattention and, even, wilfulness on the part of their employees (in anoperational environment). In a design organisation, management do not believe that theirorganisation can influence the safety of future operations (such as ATM). Many messages may

1Safety Culture Maturity is a Registered Trademark of the Keil Centre Ltd, 2003.

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flow from management, but the majority still reflect the organisation's primary production goals,often with 'and be safe' tacked on at the end.

At the Involving stage (Level 3), the foundations are laid for acquiring beliefs that safety isworthwhile in its own right. By constructing deliberate procedures, an organisation can force itselfinto taking safety seriously. At this stage the values are not yet fully internalised, the methods arestill new and individual beliefs generally lag behind corporate intentions. However, a safetyculture can only arise when the necessary technical steps and procedures are already in placeand in operation. Level 4 means the organisation really gets to grips with safety issues withcommensurate resources, and at Level 5 the organisation is largely controlling and managingsafety effectively but without complacency, and is continually improving its efforts.

Safety culture in other research and development organisations:

In a paper by Vecchio-Sadus & Griffiths (2004), a mineral processing and metal productionresearch and development organization (similar in many ways to the EEC) was used as a casestudy to show how occupational health and safety marketing strategies can be used to influencebehaviour and promote management commitment and employee empowerment to enhancesafety culture. In order for health & safety promotions to have an impact on peoples behaviour,Vecchio-Sadus & Griffiths (2004) think it is important to use marketing strategies. In fact, they

report improvements in:

(i) safety culture (accountability and commitment by management; an increase in thenumber of employees taking ownership of their work environment and knowledgeimprovement);

(ii) improvements in risk management (increase in the number of risk assessments; betterjob safety procedures; improvements to the workplace, plant & equipment)

(iii) improvement in overall performance (substantial decrease in lost time injury rate;decrease in compensation claims; improvement in the investigation and documentation ofincidents; winning research contracts because of the safety systems and culture)

The aims of carrying out safety climate maturity surveys in organization in general are to:

(i) assist in informing senior management about cultural or behavioural issues and

developing effective safety improvement plans(ii) for developing managements thinking about the type of organisation they are

managing and where they want to go(iii) encourage managers to develop the organisations safety maturity(iv) provide a practical framework for developing improvement plans and selecting

appropriate interventions (as the level of safety maturity influences theappropriateness and effectiveness of different safety improvement techniques).

Objectives of EEC SCS

More realistically, the initial objectives of surveying the EEC safety culture was to:

(i) measure a baseline of staff & contractors perceptions of safety in the EEC in order to(ii) help implement some steps to improve the safety culture.

3. MethodThe EEC Safety Culture Survey is based on traditional measures adapted to ATM and then toR&D. It looks at the attitudes of a cross section of the workforce. The questionnaire has 5 levelsof maturity where organisations can progress sequentially by building on their strengths andremove their weaknesses. Six organisations have developed and tested Safety Culture(ISO, 1990 ; Fleming et al, 1999 ; Sharp et al, 2002 ; Nickelby et al, 2002 ; NATS, 2002 ; Hudson,

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2001), mainly in the offshore oil industry. Five different methods of measuring the level of maturitywere developed. The 5 maturity levels labelled by Fleming et al (1999) at the Keil Centre havebeen used for the purposes of the EEC Safety Culture Survey (SCS):

Level 1 Emerging- safety defined as technical & procedural solutions and compliance withregulations; safety not seen as key business risk; accidents seen as unavoidableLevel 2 Managing - safety seen as a business risk; safety solely defined in terms ofadherence to rules & procedures; accidents seen as preventableLevel 3 Involving - accident rates relatively low (reached plateau); management thinkfrontline employees are critical to improvements; safety performance is actively monitoredLevel 4 Proacti ve - managers/staff recognise that a wide range of factors cause accidents;organisation puts effort into proactive measures to prevent accidentsLevel 5 Continually Improving - sustained period of no recordable or high potentialincident, but no feeling of complacency; constantly striving of finding better ways of improvinghazard control

The SCS, developed at Eurocontrol, has 21 Elements which are contained within 4 mainelements:

(i) Management Demonstration(ii) Planning and Organising for Safety(iii) Communication, Trust and Responsibility

(iv) Measuring, Auditing and Reviewing

Table 1 provides some examples of the 21 Elements, giving a flavour of what is contained in theEmerging and Continually Improving levels. These elements were developed based on theresearch of five research groups (Fleming et al, 1999; Sharp et al, 2002; Nickelby et al, 2002;NATS, 2002; Hudson, 2001), who have published the key elements which they believe todescribe the Safety Culture of the organisations they were measuring. Three of the researcherswere measuring safety culture maturity in operational environments (Fleming, 1999; NATS, 2002;Hudson, 2001); Sharp et al (2002) was measuring the safety maturity in design; and Nickelby etal (2002) were measuring human factors maturity in design. Surprisingly, there was quite a lot ofdifference in the key elements examined by the different researchers. However, there were asmall number of common elements for each of the maturity models, such as Training andOrganisational Learning.

Procedure

The first draft of the questionnaire was shown to four key people in the organisation to determinethe relevance of the items to the ATM research and design organisation. Some comments weremade regarding the relevance of some of the statements in the questionnaire, such as the use ofincident and accident reports, as they are not so relevant in an R&D centre compared to anoperational centre. A cross-section of 40 staff within the EEC were targeted for the main survey.The participants were from different projects, at different levels in the organisation and the sampleincluded contractors. The participants were selected from the personnel list to ensure a crosssectional sample was chosen. The selected participants were from across different departments;different types of expertise and different levels of responsibility. The participants were initiallycontacted by e-mail and provided with information about the study. Participants were then askedto join a group of about 10 others (for a designated meeting) to complete the survey individually.

At this meeting, participants were provided with the background and purpose of the study andinstructions on how to complete the questionnaire. Participants were encouraged to askquestions before and during the session when necessary. The survey was carried out in March,2003 and a total of 36 participants responded.

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Table 1. Examples of Statements from the Safety Culture Survey Tool

Element Lower Levels of Element (1-2) Higher Levels of Element (4-5)

1 ManagementCommitment toSafety*

Safety is considered an employeeresponsibility

Lip service is paid by senior managementto the importance of safety commitment

Senior management demonstrate commitment tosafety

Management & staff frequently discuss safety

Good safety behaviour is recognised

2 SafetyPerformanceGoals*

Safety goals are only assigned as an ad

hoc response to an incident and tend to bebased on previous experience only

Goals are set with reference to external

benchmarks and internal historyImprovement targets are set

3 ImpactThere is no mechanism for results of safetyactivity to influence management or design

decisions

Business processes ensure that safety hasauthority to enforce design changes or stop a

project

4 Investment &Resource

Al locat ion*

Little or inappropriate provision is made forresources or facilities to conduct safety

activity

Organisation makes strategic investments indeveloping organisation wide safety processes

5 Policy &Strategy onSafety

No organisation wide safety policy orstrategy

Safety activities occur in an unsystematic,unplanned way

Documentation and accessible organisation -widepolicy of safety

Monitoring of policy and strategy forms an integralpart of the organisations business processes

ManagementDemonstration

6 Safety versusProductivity*

Safety assessments are not undertakenbecause they often interfere with getting

the work done

Staff are encouraged to take account of safety indesign, which is fully resources and supported andit is encouraged over and above getting the project

completed on time

7 Safety PlanningSafety is not pre-planned ad occurs in an

ad hoc, unsystematic mannerStrategic planning for safety is automaticallyinitiated as part of core business processes

8 Training &Competence

Staff are assigned to safety activities basedon their availability, rather than on having

training or relevant experience

A comprehensive safety training programme exists

Competence standards are used

The effectiveness of training is measured

9 Knowledge ofATM Risks*

Employees are unaware of the impact thattheir work has on future ATM safety

All staff are aware of new and recurring ATM risksand fully understand how their work impacts safety

Planning&

Organising

10 RiskAssessment &Management

Risk assessment is reliant on individualexperience from specialists or experienced

managers

Risk information is routinely used in planning

There is wide employee involvement in riskassessment

11 CommunicationThere is no feedback to staff regarding

ATM safety issuesStaff regularly bring up project safety concerns and

feel confident to raise them with management

12 Integrated

Teams*

Safety effort is external to project teams Safety personnel have a core role in project teamsand have status at relevant meetings

13 Involvement ofEmployees*

There is limited employee attendance insafety activities/ meetings

Employees are heavily involved in contributing tothe design, implementation and measurement of

safety related changes

14 Relationship w/External Regulator

The objectives of the EEC and the safetyregulator are diametrically opposed

Regular audits are undertaken by the regulator andviewed as constructive monitoring of safety

15 Involvement ofStakeholders

No formal provision is made for gainingaccess to stakeholders

Appropriate and representative stakeholders areengaged at the right time on projects

16 Trust &Confidence*

Trust and confidence of employees isassumed by management

Employees are confident that complete pictures ofsafety performance and progress against targets

are communicatedCommunication,Trust&

Responsibility

17 Responsibilityfor Safety

Safety specialists undertake safety activityin isolation from staff

Everyone in the organisation believes and acceptsthat safety is their responsibility

18 OrganisationalLearning

No process to assess or feedback safetylearning ; Information is shared on a need

to know basis

A safety information system promotes sharing ofsafety issues and learning through the effective

presentation of information19 Safety

ManagementSystem / Audit

The concept of a SMS is not recognised ;Isolated policies and procedures exist

A comprehensive SMS exists and covers allaspects of safety and is designed to be practical

and achievable for all employees

20 Achievementof SafetyTargets

Criteria for determining whether safetytargets have been achieved are applied ad

hoc and tend to be inappropriate

Business processes actively identify theachievement of safety targets as criteria for thesuccess of a project and they form important

milestones

Measuring,Auditing&

Reviewing

21 Test of safetyin design

Test and evaluation of safety issues tendsto occur ad hoc in response to specificincidents and may not be appropriate

Information critical to H&S management is fed backfrom the safety tests and evaluations across the

organisation

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4. ResultsThe overall results indicated that the Elements with the highest average scores all came from theManagement Demonstration category, including: Management commitment to safety; Safetyperformance goals Investment and Resource Allocation and Policy and strategy on safety.The Elements with the lowest average scores included: Safety management system;Responsibility for Safety, Integrated teams and Risk assessment and management. The

average standard deviation between respondents was +/-0.87, indicating a fairly wide variety ofresponses.

Five Best Areas Identified by the SCMM Survey

The following five Key Elements were chosen as the most positive out of the 21 Key Elements.

Management Commitment to Safety

Safety Performance Goals

Policy & Strategy on Safety

Trust & Confidence

Test & Evaluation of Safety in Design

These key elements were thought to be between Levels 2 and 3 by the respondents, indicatingthat although they were not the worst performing elements, they are by no means indicating thatthe EEC has a good safety culture. To have a good safety culture, the EEC would need to reachabove Level 3.

4.2 Five Main Problem Areas Identified by the SCMM Survey

The following paragraphs describe the definitions of the Levels for each of the above 5 KeyElements and the next level should be the next aim for the EEC.

1. Safety Management System/ Auditing Safety The element thought to be weakest in the EEC was Safety Management System /AuditingSafety from the fourth section: Measuring, Auditing and Reviewing. The standard deviation (+/-

0.82) indicates that there was only a little variation between respondents.

WHERE WE WANT TOBE

SMS is under development SMS exists but is not comprehensive Recognises the safety impact of

organisational changes Few employees understand policy &

local procedures linkChange management exists for un its& equipment There is a recognised need to include

people & organisational structure

effects in change analysis Process and checklists exist for

assessing changesAd-hoc safety audits are undertakenin response to problems

WHERE WE AREBenefits of a SMS are not fullyrecognised There is no understanding of the

link between policy & proceduresThe impact on safety of changes tounits & equipment is recognised A checklist of key points exists to

use to assess change There is much reliance on

managers experienceThe benefits of safety auditing are

being recognised Ad-hoc audits occur but there is no

strategy underlying them

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2. Integrated TeamsThe element thought to be 2

ndweakest in the EEC was Integrated Teams, which is under the

main third section of Communication. The standard deviation (+/-0.86) indicates that there wasnot variation between respondents.

WHERE WE WANT TOBE

EEC staff work as local teams tomeet local needs Individuals consider safety

implications in all actionsHigh level cross organisationalissues are addressed by formalcross company teams Teams are set up to address

particular high-level company widesafety issues

A small number of reasonably seniorlevel staff are involved in this activity

Safety personnel are core to project

WHERE WE AREThe safety benefits of team-working are recognised Individuals recognise that their

actions have safety implications onothers

Small local groups are formed inan ad-hoc manner to addressparticular issues

Safety effort is carried out externalto project teams although they dohave ready access to project teammembers and information

3. Responsibility for SafetyThe element thought to be 3

rdweakest in the EEC was Responsibility for Safety from the

Communication section. The standard deviation (+/-0.83) indicates that there was only a littlevariation between respondents.

WHERE WE WANTTO BE

Staff initiate some safetyactivities

Risk assessments are carriedout by staff before any change ismade

There is considerable reliance onsafety specialists for safety advice

WHERE WE ARESafety speciali sts areconsidered to be accountable

for safety Safety specialists undertake

safety activity in isolation fromstaff

Safety is generally assumed tobe the responsibility of thesafety department

Staff believe that safety personnelshould carry out all riskassessments etcStaff are aware that they sharesome responsibility for safety

Staff take action based onsafety specialists advice

Safety activities are led bysafety specialists

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4. Risk Assessment and Management

The element thought to be 4

th

weakest in the EEC was Risk Assessment and RiskManagement from the section Planning and Organising for Safety. The standard deviation (+/-0.81) indicates that there was only a little variation between respondents.

WHERE WE WANTTO BE

Limited portfolio of reactive &proactive safety measuresexists. Risk assessment areapplied to non-routine tasks

Mainly reactive safety measuresare in place but it is recognisedthat more proactive measuresare required

Risk assessments are fullydocumented.

Only safety specialists areinvolved in risk assessment

The effectiveness of safetymeasures is starting to be

considered

WHERE WE AREThe need for safety measures toassess trends is recognised. Alimited portfolio of reactivesafety measures exists. Anawareness of the importance ofrisk assessment exists

Attention is concentrated on afew (up to 3) reactive safetymeasures

Risk assessments are used as aproactive measure to identifysafety risks

A non systematic riskassessment process is in use

Risk assessment may beinappropriate and is reliant onindividual experience fromspecialists or experienced

5. Training and CompetenceThe element thought to be 5

thweakest in the EEC was Training and Competence from the

section Planning and Organising for Safety. The standard deviation (+/-0.64) indicates that therewas only a little variation between respondents.

WHERE WE WANTTO BE

WHERE WE AREA limited safety trainingprogramme exists

An employee safety trainingprogramme exists

Safety training is provided asneeds arise on an ad-hoc basison specific projects or activities.

Mainly focused on classroomtraining.

There is a reliance on transfer ofskill / knowledge from oneworker to a trainee.

Competence standards are notbeing developed.

Training is often provided inresponse to problems.

Advice tends to be based onpast activities and experience

Front-line staff receive trainingas required.

Staff may be assigned to work on

safety activities based on theiravailability, rather than havingtraining or relevant experience,though they will usually besupervised by someone who isqualified

Staff assigned to carry outsafety activities will haveexperience in areas related tosafety

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5. Conclusions

The overall results from the first Safety Culture measurement of the EEC that took place in March2003, showed that the EEC has a reasonable degree of safety culture, but that there is room forimprovement. The SAGE (Safety Awareness Group in the EEC) met to (i) determine the prioritiesfor improvement and (ii) develop a suitable action-plan based in part on the issues thought to

require the most improvement:

1. Safety Management System(i) A SMS needs to be developed more fully. The concept and benefits of a SMS needs to be

fully recognised by EEC; a link between the SMS policy and the local tasks needs to beunderstood by employees. Initially, information (in the form of discussions/workshops)needs to be provided for project managers in order for them to become more familiar withwhat the SMS is and how this will impact their projects.

(ii) Action Plan. The group decided that a SMS for the EEC should be developed based on theSMS developed by Eurocontrol Headquarters (Safety Management Unit). The SMU SMS iscurrently under development (a first draft is due to be completed in April 2004), anddiscussions between the SMU and EEC to develop a customised version will beginJanuary, 2004. A first release of the EEC SMS is planned for September, 2004. The main

differences between the two SMSs will be policies for simulations; key risk areas and rolesand responsibilities. The key part of the SMS issue was thought to be the link between theSMS policy and the local task needs to be understood by the staff and contractors.

2. Auditing Safety(i) A strategy for auditing safety within projects needs to be developed based on the structure

of the SMS. The safety audit will be a proactive means to assess what safety issues have(and have not) been addressed in the project. Initially, safety audits could be used inresponse to safety problems, although the aim will be to carry them out on a more regularbasis.

(ii) Action Plan. Develop an Audit Approach, and initially use it with SSP. Further discussionswill be made within SAGE to discuss the possibility of external (and ad hoc) audits.

3. Cross-company Teams.(i) Cross-company (cross-discipline) teams should be set up to address particular high-level

company wide safety issues.(ii) Action Plan. A number of cross-discipline/company safety groups have recently been put in

place in the EEC, internally they include SAGE; externally they include the Safety R&Dreview group; Eurocontrol (HQ) Review. However, it was thought that 2 additional internalgroups should be formed in order to spread safety awareness through the EEC. (i)Business Area Leaders at the WBS level what are you doing practically, where the SRTwould provide coaching the group. And (ii) Internal Feedback Group or user group madeup of people who will be using safety methods (or working with people from the SRT) on aday-to-day basis.

4. Risk Assessment & Management(i) More emphasis should be placed on the quality and objectiveness of risk assessments, as

well as a more systematic risk assessment procedure.(ii) Action Plan. This is currently being undertaken in SAND (Safety in New Designs). Perhaps

more awareness of this work within the EEC is required.

5. Training & Involvement in Safety Activities(i) Team members should be encouraged to use and act on advice given by the safety

specialists. In addition, team members should be to be involved in safety activities (such asrisk assessments) with the support of safety personnel and should be trained to carry outthese safety activities. Some senior staff should be involved in the safety activities.

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(ii) Action Plan. The first part of this issue is being covered within the SAND project. Safetytraining is being undertaken for the SAM methodology; TRACEr and HAZOP training in2003. The focus is on training the SRT (Safety Research Team) members and projectleaders initially. Plans for further safety training are also in hand for 2004. Further safetyawareness training sessions are planned for the Weekly Information Corners (WIC) in theform of video presentations on ATC incidents.

A further task to be undertaken to improve the initial EEC safety culture maturity questionnaire.The maturity of the EEC safety culture will be measured again September, 2004, to see if anychange has occurred.

4. Discussion

Implementation Plan and Accomplishments

The five main problem issues identified by the SCS were used to develop an implementationplan, which was adopted by SAGE (Safety Awareness Group in the EEC). The goal of SAGEwas to (i) determine the priorities for improvement and (ii) develop a suitable action-plan based inpart on the issues thought to require the most improvement. The implementation plan includedthe following items:

1. Safety Management System.A SMS needs to be developed more fully. The concept andbenefits of a SMS needs to be fully recognised by EEC; a link between the SMS policy and thelocal tasks needs to be understood by employees. Initially, information (in the form ofdiscussions/workshops) needs to be provided for project managers in order for them to becomemore familiar with what the SMS is and how this will impact their projects.It was decided both ata very high level (Eurocontrol Agency Board), and within the SAGE group, that a SMS for theEEC should be developed consistent with the SMS being developed by Eurocontrol Headquarters(Safety Management Unit - SMU). The main differences between the two SMSs will be policiesfor simulations; key risk areas and roles and responsibilities. The key part of the SMS issue wasthought to be the link between the SMS policy and the local task needs to be understood by thestaff and contractors. This is currently being undertaken and is on schedule.

2. Auditing Safety.A strategy for auditing safety within projects needs to be developed based onthe structure of the SMS. The safety audit will be a proactive means to assess what safety issueshave (and have not) been addressed in the project. Initially, safety audits could be used inresponse to safety problems, although the aim will be to carry them out on a more regular basis.This has been delayed until 2006, as it was thought other issues needed to be dealt withbeforehand.

3. Cross-company Teams. Cross-company (cross-discipline) teams should be set up to addressparticular high-level company wide safety issues. A number of cross-discipline/company safetygroups have recently been put in place in the EEC, internally they include SAGE; externally theyinclude the Safety R&D review group; and Eurocontrol (HQ) Review. However, it was thought thatfurther additional internal groups should be formed in order to spread safety awareness throughthe EEC. This has been started initial with Safety Assessment User Group meetings.

4. Risk Assessment & Management. More emphasis should be placed on the quality andobjectiveness of risk assessments, as well as a more systematic risk assessment procedure.This is currently being undertaken in SAND (Safety Assessment for New Designs). The SANDwork has increased in size and scope, and more people are now being trained in safetyassessment skills in the EEC.

5. Training & Involvement in Safety Activities. Team members should be encouraged to useand act on advice given by the safety specialists. In addition, team members should be to beinvolved in safety activities (such as risk assessments) with the support of safety personnel and

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should be trained to carry out these safety activities. Some senior staff should be involved in thesafety activities. The first part of this issue is being covered within the SAND project. Safetytraining is also being undertaken for more general safety assessment methods. Further safetyawareness training sessions are planned and have been occurring for the general staff WeeklyInformation Corners (WIC) in the form of video presentations on ATC incidents. A trainingpackage for SAND has been produced and is currently being delivered internally.

6.A further task to be undertaken to improve the initial EEC safety culture questionnaire. Thematurity of the EEC safety culture will be measured again April 2005, to see if any change hasoccurred. This is currently being discussed, and further refinements to the tool have been initiatedfrom comments by participants.

Final CommentsThe Survey gains a grass roots perspective on safety. The participants are anonymous, they area randomised cross-section, and say what they feel is the real state of safety. This seems to bestill the most appropriate way to gain an honest assessment of safety culture/climate, althoughperhaps interviews might enhance the accuracy (by clarifying questions etc.) and reduce thevariation of responses. The survey also takes the issues of safety culture out to the troops,involving them and not only the chain of command. The SCS was undertaken as a questionnaire

survey, because of the limited time to carry out interviews with 40 people, and because it wasthought that if the participants were interviewed by a member of EEC staff, the survey results maybe influenced. With some additional time spent on group discussions with SCS participants afterthe survey, it may be possible to examine the important issues in more detail and come up withmore focused and relevant issues to the EEC.

Acknowledgements: The authors would like to express their sincere gratitude to all participantsin the study.

Caveat: The opinions expressed in this paper are those of the authors only and do notnecessarily reflect those of the EEC or parent or related organisations.

REFERENCES

Fleming, M. (1999) Safety Culture Maturity Model. UK HSE Offshore Technology Report OTO2000/049, HSE Books, Norwich.

Hudson, P. (2001) Aviation Safety Culture. Safeskies Magazine.

Reason, J. (1997). Managing the Risks of Organisational Accidents. Hants, England, AshgatePublishing Ltd.

Sharp, J.V., Strutt, J.E., Busby, J. Terry, E. (2002) Measurement of organisational maturity in designingsafe offshore installations. Proceedings of 21

stInternational Conference on Offshore Mechanics and

Arctic Engineering, June 23-28, Oslo, Norway.

Vecchio-Sadus, A.M. and Griffiths, S. (2004) Marketing strategies for enhancing safety culture, SafetyScience, 42, 601-619.

BSI (2000) ISO 9001 Quality Management Systems Guidelines for Performance Improvement,London.

Nickelby (2002) Framework for assessing human factor capability. UK HSE Offshore TechnologyReport OTO 2002/016, HSE Books, Norwich.

NATS (2002) The Safety Culture Assessment Framework for UK National Air Traffic Services.

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