Roadmap to World Class Safety

and Compliance Culture

2

Nothing ever goes away until it teaches us what we need to know

Learning Our Lessons

Focus should be on the risk factors, not the bad

outcomes (behaviors, situations, activities)

Lessons are effectively learned when we:

Identify

Measure

Change

Sustain

ROOT CAUSE

LEADING INDICATORS

CULTURAL NORMS

SYSTEMS

2

The identification of root cause for multiple events provides a roadmap of Attributes that lead to world class

safety and compliance performance

Identify – Correlating Cause and Outcome

Attributes are witnessed by ancillary targets that represent

common activities of an organization

Examples of business attributes and observable targets include:

Attribute Ancillary Target

Teach Leaders follow the rules

Ownership Housekeeping

Execution Regulatory requirements

Discipline Paperwork compliance

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1

1.5

2

2.5

3

3.5

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Jan Feb Mar Apr May Jun Jul Aug

Attribute Performance Vs. Damage Occurrences

TO Damage Count Average Assessment Scoring

Identify – Correlating Cause and Outcome

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Identify – Correlating Cause and Outcome

Statistical Analysis Confirms a Strong Inverse Correlation

P Value of .001 supports

confidence interval above

95%

2

Measure

Attributes are witnessed

“Management by Objectives and Self Control”“Management by Objectives and Self Control”

2

Measure – A Function of Change

Attributes are witnessed

“Management by Objectives and Self Control”

Measure of Outcomes (Y)

• Identifies when change is needed or desired

Measure of Leading Indicators (X)

• Predictive tool that detects movement in culture

Baseline Measures

• Establishes rate of change and risk levels

• Acts as a directional compass for movement in culture

• Essential for change

2

0.0

1.0

2.0

3.0

4.0

5.0

Surveillance

Awareness

Teach

Protect

Communicate

Ownership

Responsibility

Rewards

MeasurementRequirements

Adherence

Execution

Commitment

Discipline

Documentation

Consequences

Endorsement

Components and Attributes of Safety Value

Assessment (2016) Assessment (2015) Previous Assessment Re-Scored Original Assessment Extrapolation

SAFETY INSTINCT

SAFETY MOTIVATIONSAFETY POLICY

SAFETY INTERVENTION

Green = Baseline

Blue = Current State

Attributes Scored by

Observable Targets

Component of Safety Value

5 Rings = Hierarchy Levels of

the Organization

Ownership Achilles

Heel of Cultural

Improvement

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Cultural Assessment and Damage Performance

Trending Analysis

30.00

32.00

34.00

36.00

38.00

40.00

42.00

44.00

46.00

48.00

50.00

20

25

30

35

40

45

50

55

60

2013 2014 2015 2016 (extrapolated)

Assessment Score Vs. Annual Damage Counts

Damage Counts Average Assessment Score

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Cultural Assessment and Injury Performance

Trending Analysis

41.00

42.00

43.00

44.00

45.00

46.00

47.00

48.00

650

700

750

800

850

900

2014 2015 2016 (extrapolated)

Assessment Score Vs. Annual injury Counts

Injury Counts Average Assessment Score

2

Change – Three Pillars of Safety Culture

Attributes are witnessed

“Management by Objectives and Self Control”

There are three core competencies at the heart of any effective

safety and compliance program

• Knowledge

• Singular understanding of what is required

• Detection

• Identifying where gaps exist

• Enforcement

• Taking the necessary steps to eliminate quality escapes

These competencies (KDE) are linked to our safety assessment

analysis, attribute performance measure and five rings of

organizational growth

2

Change – Three Pillars of Safety Culture

Attributes are witnessed

“Management by Objectives and Self Control”

2

Change – Improving Core Competencies

Attributes are witnessed

“Management by Objectives and Self Control”

Organized activities and system tools are required to grow core

competencies

• Knowledge

• Training programs

• Robust communications (lessons learned)

• Detection

• Continuing Analysis and Surveillance System (CASS)

• Accountable and reliable audit program (360)

• Effective Safety Action Team (SAT) engagement

• Enforcement

• Formalized Intervention process

• Team engagement

• Consequences

2

Safety Action Teams are an essential element of change management. Effective SAT groups grow the core competencies (KDE) and build engagement at the floor level.

• Team meetings are designed to engage both leaders and floor level co-workers in the pursuit of a safe and compliant workplace

• Engaging team members from all levels broadens viewpoints and ideas

• Floor level workers have first hand knowledge of impediments to safety and compliance

• Risk analysis and risk mitigation is a key component of the process

• Formalized risk analysis tool standardizes the way we identify and react to safety and compliance risk system wide

• Interface an alignment with internal and regulatory auditing

• Identifies systemic trends and failure modes

• Roll up to senior level round table

• provides commitment and resources from Division leaders

Change - Safety Action Teams (SAT)

2

Change - Safety Action Teams (SAT)

The Kubler-Ross change curve demonstrates the effects of change on moral and

self esteem. Safety action teams reduce the duration of negative effects through

engagement and functional partnering at all levels of the organization.

2

360 Audit is a full circle program that expands knowledge, detection and enforcement through reliable and meaningful audits that are tracked, substantiated and work to drive positive change

System standardized audit regimen provides baseline for trending and systemic failure

Mobile technology allows audits to be completed on the floor in 15 minutes

Photo component validates audit findings and establishes visual history of change

Built in help aids bolsters supervisor knowledge of internal and regulatory requirements

Intervention requirements sets the stage for supervisor interaction with floor level workers to drive enforcement

Alignment with internal and external audit and detection regimens

Highlights top 5 findings at station and system level for SAT action and roll up

Change - 360 Audit ProgramProviding an accountable, simplified process for change

2

360 Audit is a full circle program that expands knowledge, detection and enforcement through reliable and meaningful audits that are tracked, substantiated and work to drive positive change

System standardized audit regimen provides baseline for trending and systemic failure

Mobile technology allows audits to be completed on the floor in 15 minutes

Photo component validates audit findings and establishes visual history of change

Built in help aids bolsters supervisor knowledge of internal and regulatory requirements

Intervention requirements sets the stage for supervisor interaction with floor level workers to drive enforcement

Alignment with internal and external audit and detection regimens

Highlights top 5 findings at station and system level for SAT action and roll up

Change - 360 Audit ProgramProviding an accountable, simplified process for change

18

0%

10%

20%

30%

40%

50%

60%

70%

 OS7e  TC1e  OS6c  HK1b  PP8c

Pe

rce

nt

System Level Top 5 Repeating Failures

OS7e Do machines have auto stops?

TC1e Are maintenance technical references present and appropriate

OS6cIs a current OSHA 300A log posted as required from February 1 through April 30?

HK1b Is the floor or area clear of rags and debris?

PP8cAre you aware of the recurrent training requirement for all technicians on compressed gas requirements?

360 Audit – Shop Level and System Wide Analysis

Enhanced Detection at Shop Level facilitates targeted local focus

System level views identifies and escalates systemic failures

Safety Action Team requirement drives accountable mitigation activity

Single source tool to enhance Knowledge, Detection and Enforcement

Repeating loop process sets the table for continuous improvement

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IDENTIFICATION OF THREATS CONTINUE WITH RISK

MITIGATION?

CONTROLS AND RISK MITIGATION OF THREAT

# Process or EventPotential Failure Mode (Threat)

Potential Effect(s) of Failure (Error or Consequence)

Seve

rity

Potential Cause(s) of Failure

Likeliho

od

Current Risk Control Measures

Detectio

n

R

i

s

k

Recommend ActionsResponsible

Person & Target Date

Actions taken to mitigate risk and date implemented

3

The use and storage of oiler equipment

Oilers not properly capped when not in use

contamination of aircraft oil product

3Failure to follow procedures / lack of resource

BInternal Audit

for GSM requirements

Y 3B

Continue with Risk Mitigation

Engineering fix that provides a more reliable capping process

Hub Station SAT's

ORD has prototyped an engineering fix to ensure caps are available, permanent and easy to use

Change - 360 Audit System

Example - Top 5 Identification and Mitigation

SAT team at ORD identified a great engineering fix that is currently in prototype

stage. With positive test results, this fix can be scrolled and implemented at stations

system wide.

4) Are oilers stored with caps on?

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Change - 360 Integration with SAT

Top 5 roll up to local SAT group results in engineering fix that is

scrolled and replicated system wide

2

Sustain – Key Component of Change Management

Attributes are witnessed

“Management by Objectives and Self Control”

Sustained growth is absolutely essential to drive and maintain a

world class safety and compliance culture

Two requirements of sustained growth are measure and control

• Measure

• Begins with a Baseline – this becomes the basis of the change rate

• Continued assessments provides objective measure of change

• 360 audit and SAT risk assessment data adds to and aligns with

assessment measure

• Control

• Measures are evaluated through statistical control

• Out of control or reverse trending are quickly identified and addressed

• Visibility to the impact on $$$

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Sustain – Statistical Control of Attribute Measure

4321

3.0

2.9

2.8

2.7

2.6

2.5

2.4

2.3

2.2

Sample

Sa

mp

le M

ea

n

__X=2.6004

UCL=2.9481

LCL=2.2526

Xbar Chart of Assessment Score

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$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

2013 2014 2015 2016 (extrapolated)

Trending - Damage Cost

Damage Cost

Sustain – Celebrating Significant Impact to $$$

Millions of dollars of saving have been realized since the program

inception in 2013 – Damage cost for Technical operations reduced

from $24M in 2013 to $3M YTD 2016

2

Roadmap to World Class Safety

Attributes are witnessed

“Management by Objectives and Self Control”

Develop the Tools

• Define key attributes - the antidote to root causes

• Construct an objective scorecard

• Build support structure – robust audit process, SAT

• Teach - how, what and why

Establish a Baseline

• Fund a process – senior level sponsor

• Conduct Baseline assessment at all major work locations

• Ensure a consistent measure – repeatability and reproducibility

• Create specific and obtainable objectives

Lead the Culture

• Stay the course - proven success

• Correlate results – scores and outcomes (rate of change)

• Stars are born – identify change champions

• Continuous improvement – opportunities for learning