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Air Line Pilots Association, Int’l
Safety ManagementRisk Management Course
Module One: Tools for Decision Makers
July 13th, 2021
Captain Helena Cunningham
Delta Air Lines - Safety Committee Chairwoman
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Air Line Pilots Association, Int’l
Day One of the Hostage Crisis
▪ Lavs
▪ Phasers – on STUN
▪ Breaks - every 45-60 minutes
▪ Emergency Exits
▪ Food plan – Hot Lunch
▪ RMC
– Day 1: Risk Management / SMS
– Day 2: ASAP
– Day 3: FOQA2 2021
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Air Line Pilots Association, Int’l
▪ Safety is…
The Question…
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Air Line Pilots Association, Int’l
▪ Explore tools to evaluate
and participate in your
company’s safety
programs
▪ Basic SMS definitions and
concepts
▪ Introduce SRA/SRM
▪ SRA exercises
Today’s Goals
4 2021
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Air Line Pilots Association, Int’l
…The CASC?
…Committee Member?
…MEC?
How Can This Help YOU…
FOCUS
5 2021
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Air Line Pilots Association, Int’l
SMS & SRM Helps You…
▪ Assess and participate in
the safety performance of
your airline
▪ Make positive change in
addressing safety issues
▪ Improve company safety
management
▪ Take emotion / politics out
of decision making
At Your Airline…
6 2021
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Air Line Pilots Association, Int’l
SMS & SRA helps you, a key stakeholder:
▪ Be more effective in risk assessment
decision-making
▪ Assess risk and help develop ALPA positions
Working with Government Agencies
and Industry Groups
7 2021
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Air Line Pilots Association, Int’l
SMS and SRM will help you manage limited or
scarce resources.
▪ You can’t afford to fix everything
▪ Process is verifiable, consistent and
documented
▪ Everyone involved can (hopefully) agree on
where, and where not to, spend
In All Cases…
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Air Line Pilots Association, Int’l
▪ Safety…
▪ Management…
▪ Safety Management
System
– Safety Risk
Assessment
– Safety Risk
Management
Todays Agenda
9 2021
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Air Line Pilots Association, Int’l
In this section we will discuss safety…
– Definitions
– Philosophies
– Concepts
SAFETY
10 2021
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Air Line Pilots Association, Int’l
Understanding the
idea of…
SAFETY
First…
Or, at least, thinking about it!
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Air Line Pilots Association, Int’l
Is it just a marketing term?
12 2021
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Air Line Pilots Association, Int’l
“… an inherent part of a well designed
system, a quality which produces known,
predictable, acceptable outcomes.”
Steve Smith, Office of System Safety
FAA
Safety is:
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Air Line Pilots Association, Int’l
“A thing is safe if its risks are judged to be
acceptable.- William W. Lowrance
“Of Acceptable Risk”
“Safety” is:
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Air Line Pilots Association, Int’l
“Safety in a system may be defined as a
quality of a system that allows the system to
function under predetermined conditions
with an acceptable minimum of accidental
loss.”
System Safety Engineering & Management,
2nd Edition, John Wiley & Sons 1990
ISBN 0471618160
Roland & Moriarty Say:
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Air Line Pilots Association, Int’l
Safety is: Let’s see…it’s a goal
… freedom from risk
… the absence of
accident precursors…
No, it’s controlled and
acceptable risk!
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Air Line Pilots Association, Int’l
Safety is …a continuous process of
identifying, eliminating, controlling, or
accepting, known hazards to achieve
acceptable levels of risk for any particular
process, activity or operation.
Steve Corrie, ALPA, FAA
How About….
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Air Line Pilots Association, Int’l
The reality is that not everyone will
agree with our definition of what is “unsafe”.
The challenge is to find out what level is
acceptable.
Our Challenge: to “sell,” or validate, our
perspective in a way that results in desired
change.
When you deal with “acceptable
level of risk…”
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Air Line Pilots Association, Int’l
“If we die, we want
people to accept it. We
are in a risky business,
and we hope that if
anything happens to us it
will not delay the
program. The conquest of
space is worth the risk of
life.”— Astronaut Virgil 'Gus' Grissom.
Context
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Air Line Pilots Association, Int’l
“Risk management is a more realistic term than
safety. It implies that hazards are ever-present,
that they must be identified, analyzed, evaluated
and controlled or rationally accepted.”
Jerome Lederer, director of the Flight Safety Foundation for 20 years
and NASA's first director of Manned Flight Safety.
Last Thought…
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Air Line Pilots Association, Int’l
▪ System
▪ Hazard
▪ Risk
▪ System Deficiency
▪ Mitigation (Controls/
System Defenses)
▪ Monitoring
More Safety Definitions…
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Air Line Pilots Association, Int’l
A group of
interacting,
interrelated, or
interdependent
elements
forming or
regarded as
forming a
collective unity
A “System”
22 2021
From “Managing Risk” by Dr. Vernon L.
Grose
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Air Line Pilots Association, Int’l
Regulatory Safety System Safety
Two Ways
to Approach Safety
23 2021
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Air Line Pilots Association, Int’l
A foundation of rules aimed to improve the
standards of safe products, services,
behavior, practice and of operating…the
level of which is governed by societal,
cultural, philosophical factors, legal systems,
technological progress and experience.
The Traditional Way –“Regulatory Safety”
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Air Line Pilots Association, Int’l
▪ You can’t write a regulation to address
every potential hazard…
▪ …but aircraft operators, designers, and
manufacturers must comply with
regulations…
– …so, the goal becomes compliance with
existing rules, possibly ignoring other hazards
Regulatory Safety Has Limits
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Air Line Pilots Association, Int’l
“Regulatory Safety” is
mostly:
REACTIVE
Inefficient - considering
what you often have to
do to change a rule!
Significant Limitation
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Air Line Pilots Association, Int’l
▪ Engineering beginnings
▪ US Mil Standard 882 – USAF contractors
were required to have a System Safety
Program
▪ Proven engineering risk based concept –
Some attempts to apply it to:
– Human performance
– Management and organizational issues
System Safety
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Air Line Pilots Association, Int’l
The application of special technical and managerial skills to
the systematic, forward-looking identification and control of
hazards throughout the life cycle of a project, program or
activity.
Calls for safety analyses and hazard control actions,
beginning with the conceptual phase of a system and
continuing through the design, production, testing, use and
disposal phases until the activity is retired.
System Safety Engineering & Management, 2nd Edition
John Wiley & Sons 1990 ISBN 0471618160
System Safety
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Air Line Pilots Association, Int’l
▪ A systematic and continuous life-cycle
process based on proactive identification of
Hazards, and analyses of their Risk.
▪ Not Reactive but…
▪ PROACTIVE
System Safety
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Air Line Pilots Association, Int’l
Active monitoring and …
Ongoing process
…a cycle
How does this compare to
Regulatory or Compliance
Safety?
System Safety requires…
IdentifyHazards
AnalyzeRisk
AssessRisk
ManageRisk
EvaluateHazardControls
ModifyProcess
IdentifyHazards
AnalyzeRisk
AssessRisk
ManageRisk
EvaluateHazardControls
ModifyProcess
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Air Line Pilots Association, Int’l
▪ Systematic, rigorous, forward-looking (proactive),
all encompassing
▪ Strict definitions (Sound Familiar?)
▪ The foundation is clear hazard identification
▪ Qualitative and quantitative risk analyses
▪ Adherence to the systematic process
▪ Performance measuring, evaluation & follow-up
System Safety Attributes
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Air Line Pilots Association, Int’l
Hazard Mitigation
before losses are sustained
PREDICTIVE
…based on “Acceptable
Levels of Risk”
System Safety applies…
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Air Line Pilots Association, Int’l
From Safety I to Safety II
Source: Eric Hollnagel, et al. (2013)33 2021
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Air Line Pilots Association, Int’l
Take 10 minutes
Break time!
202134
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Air Line Pilots Association, Int’l
Fundamentals
Welcome Back!
Management
35 2021
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Air Line Pilots Association, Int’l
Organizations, Mishaps,
“Safety Culture”
Let’s look at…
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Air Line Pilots Association, Int’l
Organizations
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Air Line Pilots Association, Int’l
Organizational value systems include
prioritization or balancing policies covering
areas such as productivity versus quality,
safety versus efficiency, financial versus
technical, professional versus academic, and
enforcement versus corrective action.
ICAO
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Air Line Pilots Association, Int’l
…or With
Let’s look at the kinds of
organizations we work In…
G
Número Uno
BP
40 2021
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Air Line Pilots Association, Int’l
▪ Blame the messenger
▪ Hide information
▪ Cover up failure
▪ Crush new ideas
▪ Shirk responsibility
▪ No employee/employer
bridging
Pathological Organization
Professor Ron Westrum-Eastern Michigan University
Ref: Complex Organizations: Growth, Struggle and Change
Prof. Ron Westrum - EMU
Out of Print
41 2021
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Air Line Pilots Association, Int’l
▪ Very structured
process
▪ Lacks flexibility
▪ Paperwork &
meetings, meetings,
meetings
▪ Sometimes necessary
▪ Sometimes effective
Bureaucratic OrganizationProfessor Ron Westrum-Eastern Michigan University
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Air Line Pilots Association, Int’l
▪ Actively seek
information
▪ Shared responsibility
▪ Welcome new ideas
▪ Continuous evaluation
▪ Good internal
communication
▪ Employee/employer
bridging rewarded
Generative Organization
Professor Ron Westrum-Eastern Michigan University
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Air Line Pilots Association, Int’l44 2021
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Air Line Pilots Association, Int’l
Why is this important?
45 2021
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Air Line Pilots Association, Int’l
▪ Technical Era
– Fly/Crash/Fix/Fly – most accidents were mechanical
failure
▪ Human Factors
– Blame and Train - every accident “Pilot Error”
▪ Technology improvements and Human Factor
awareness = Low Accident Rate
▪ Organizational Era
– Safety Management?
– Most potential for further accident rate reduction
▪ 2020s – Resilience Engineering?
Safety Evolution
46 2021
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Air Line Pilots Association, Int’l
Overlooking the Obvious
The Organizational Accident
Dr. James Reason, Manchester University
47 2021
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Air Line Pilots Association, Int’l
…an accident that has, as its root causes:
▪Corporate culture, or
▪Corporate decision making
▪Or… Lack Thereof!
The Organizational Accident is..
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Air Line Pilots Association, Int’l
Organizational Failure ModelProfessor James Reason, University of Manchester
Active Failure
Decision-makers – Fallible decisions
Line Management - Deficiencies
Preconditions – Psychological precursors of
unsafe acts – Environment
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Air Line Pilots Association, Int’l
“Process”
instead of
“Events”
Organizational safety is all about…
50 2021
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Air Line Pilots Association, Int’l
This is a “Process”
51 2021
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Air Line Pilots Association, Int’l
….two components:
▪Latent Conditions
▪Active Failures
The Organizational Accident has…
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Air Line Pilots Association, Int’l
The errors and violations having an
immediate adverse effect are unsafe acts
Eliminating an Active Failure Event prevents
one accident from happening
Active FailuresProfessor James Reason, University of Manchester
53 2021
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Air Line Pilots Association, Int’l
“Event Tree”
Root Causes
Active Failure
54 2021
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Air Line Pilots Association, Int’l
Eliminating an Active Problem
Root Causes
X
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Air Line Pilots Association, Int’l
…situations placed in the system by decision
makers, or…
…conditions which are placed
in the system by decisions or
actions of those at some
distance from the immediate
operation
Latent Conditions
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Air Line Pilots Association, Int’l
Organizational Process
▪ Inadequate system
hazard identification
and risk management
▪ Cut-Backs in
Training
▪ Decreased
Surveillance
For Instance
Resource based safety decisions
Latent Conditions
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Air Line Pilots Association, Int’l
…may lie dormant
for a long time,
and only become
evident when they
combine with a
triggering
mechanism to
breach the
system’s defenses
Latent Conditions…
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Air Line Pilots Association, Int’l
…can trigger an Active Failure, or combine
with an active failure to result in a “loss.”
Eliminating a Latent
Condition may
eliminate many
incidents or
or accidents
Latent Conditions…
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Air Line Pilots Association, Int’l
▪ Avoid the temptation to focus on the smoking
hole – the Event
▪ Focusing on the Event or the Individual dooms us
to repetition
▪ Focus on the Process to get to the root cause
Where Should we Focus?
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Air Line Pilots Association, Int’l
Eliminating a Latent Problem
Investigation
XLatent
61 2021
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Air Line Pilots Association, Int’l
We need to get to
“latent conditions”
as well as active
failures!
“Band Aid” solutions waste resources and deal with the Event (effect) - not the Process (cause.)
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Air Line Pilots Association, Int’l
Procedures, Regulations and Risk Controls
are established at a point in:
▪ Time
▪ Technology
▪ Culture
And What About Drift?
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Air Line Pilots Association, Int’l
▪ Pressures are always in flux:
– Time - OTP - Cost - Labor, Fuel, Supervision
etc.
▪ Things change but Procedures do not.
▪ Front Line employees and Supervisors meet
the challenge, adapt…
▪ Organizational Latent Condition:
– Stale procedures
– Now working past the safety barrier
Safety Drift…
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Air Line Pilots Association, Int’l
Operational/Safety Drift…
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Air Line Pilots Association, Int’l
Reason’s Organizational Accident is a
problem for any organization
“Every accident, no
matter how small,
is a failure of
organization.”K. R. Andrews, British jurist 1907
So What?
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Air Line Pilots Association, Int’l
They illustrate the failings of an
operating “culture” without safety
securely embedded
What do Organizational Accidents
Illustrate?
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Air Line Pilots Association, Int’l
Errors - Easy
▪ Slips and memory lapses
▪ Misunderstandings
▪ Mistakes
– Skill based
– Rule based
– Knowledge based
Violations – Complicated
▪ Deviation from standard procedures (SOP)
▪ Deviation FAR/Company Policy
Two Types of Unsafe Acts…
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Air Line Pilots Association, Int’l
Deliberate
▪ Intentional
▪ Disregard
▪ Willful
▪ Negligent
▪ Misconduct
Violations are complicated!
Not Deliberate
▪ Error
▪ Misunderstanding
▪ Knowledge
▪ Mistake
▪ Well-intentioned
It may be a violation of the rules
but …69 2021
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Air Line Pilots Association, Int’l
The Compliance Philosophy represents a
focus on using—where appropriate—non-
enforcement methods, or “Compliance
Action.”
The New Improved FAA…
Compliance Philosophy
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Air Line Pilots Association, Int’l
Compliance Action is a new term to describe
the FAA’s non-enforcement methods for
correcting unintentional deviations or
noncompliance that arise from factors such
as flawed systems and procedures, simple
mistakes, lack of understanding, or
diminished skills. A Compliance Action is not
adjudication, nor does it constitute a finding
of violation.
Compliance Philosophy (2015)
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Air Line Pilots Association, Int’l
A Compliance Action is
intended as an open and
transparent safety
information exchange
between FAA personnel and
you. Its only purpose is to
restore compliance and to
identify and correct the
underlying causes that led to
the deviation.
Compliance Philosophy
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Air Line Pilots Association, Int’l
Examples of Compliance Actions include on-
the-spot corrections, counseling, and
additional training (including remedial
training).
Compliance Philosophy
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Air Line Pilots Association, Int’l
▪ What is Drift?
▪ What is a Latent Condition?
▪ Which end of the cheese is the source of
your most worrisome problems ?
Review
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Air Line Pilots Association, Int’l
…and What is It?
How Do We Depend on “Culture”…
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Air Line Pilots Association, Int’l
Corporate Culture
“The Way We Do Things Here”
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Air Line Pilots Association, Int’l
A Safety Culture
“Set of beliefs, norms, attitudes, roles and
social and technical practices concerned
with minimizing exposure of employees,
managers, customers and members of the
general public to conditions considered
dangerous or hazardous.”
Thesis
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Air Line Pilots Association, Int’l
Good Culture ▪ Policy is followed
through Practices
(Habits) - even when
no one is looking!
▪ Middle managements’
expectations are the
same as front-line
employee.
▪ Executive Management
is involved.
Culture Builds and Maintains Habits
Poor Culture ▪ Gap between Policy
and routine practices.
▪ Middle management is
squeezed and unable
to be balanced.
▪ Executive Management
is absent.
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Air Line Pilots Association, Int’l
A healthy safety
culture for both
the organization
and the individual
is the Goal.
Safety Culture
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Air Line Pilots Association, Int’l
▪ Probably know it when
you see it!
▪ Components:
– Informed
– “Just” or Professional
– Reporting
– Learning
What is a Safety Culture?
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Air Line Pilots Association, Int’l
It is…
▪ An informed culture
▪ People are trained for both their duties and
Safety Management.
▪ People understand hazards and risk and;
– work continuously to identify and overcome
threats.
What is a Safety Culture?
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Air Line Pilots Association, Int’l
A just or professional culture
▪ Errors are understood as unavoidable but
willful violations not tolerated.
– Clear “exclusion” process (ASAP Big 5).
▪ Workforce knows, and agrees, on what is
acceptable and unacceptable.
▪ Pilots and Company agree on, and follow,
data protection and reporting agreements.
A Safety Culture is
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Air Line Pilots Association, Int’l
A reporting culture
▪ People are encouraged to voice safety
concerns.
▪ People feel safe to self-report errors and
observations.
▪ When safety concerns are reported they are
analyzed and appropriate action is taken –
with feedback.
– No Black Hole
A Safety Culture is…
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Air Line Pilots Association, Int’l
Five Characteristics of Effective
Reporting
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Air Line Pilots Association, Int’l
A learning culture
▪ The organization investigates and
documents every report.
▪ Safety issues are brought formally to the
decision makes – continuous improvement.
▪ Staff are updated on safety issues by the
leadership.
▪ The organization is flexible and able to
change when warranted.
A Safety Culture is…
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Air Line Pilots Association, Int’l
Leadership at every
level forms a
“partnership” with
employees to develop
and maintain an
effective safety
program
In a “Safety Culture”
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Air Line Pilots Association, Int’l
▪ Sufficient resources are allocated to
maintain an efficient and safe operation –
flexible to change
▪ Safety concerns and suggestions are
acknowledged
▪ Feedback is provided on decisions
▪ Decisions for “no action” or “acceptable
risk” are explained
An “Aware” Management
Makes Certain that…
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Air Line Pilots Association, Int’l
A healthy safety culture relies on a high
degree of trust and respect between
personnel and management and must
therefore be created and supported at the
senior management level.
ICAO
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Air Line Pilots Association, Int’l
Safety Promotion — Includes training,
communication, and other actions to create
a positive safety culture within all levels of
the workforce…
FAA
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Air Line Pilots Association, Int’l
A “safety culture”
that got lost
Antithesis
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Air Line Pilots Association, Int’l
Seeing the same
operational
discrepancy so
many times and
with such regularity
that it becomes the
new system “norm”
Normalized Deviance
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Air Line Pilots Association, Int’l
Normalized Deviance vs. –
HF ViewWhy do people break
rules?
▪ Unnecessary
▪ Burdensome
▪ Just for the
inexperienced
▪ Just once
▪ They were just
guidelines
▪ Everybody does it
➢Humans work the
easiest, quickest, most
efficient way
intrinsically
➢Rule-breaking is part of
human nature
➢Deviation is normal!
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Air Line Pilots Association, Int’l
▪ Developed nuclear submarine technology
based on the Manhattan Project
▪ Over 60 years without a single process
safety accident
▪ Supporter of deviance;
Normalization of Excellence
▪ Outcast of naval leadership
Admiral Rickrover
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Air Line Pilots Association, Int’l
All done!
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