< Previous2-16 Safety Management Manual (SMM) • Unintended consequences. The introduction of new hazards and related safety risks associated with the implementation of any mitigation alternative. • Time. Time required for the implementation of the safety risk mitigation alternative. 2.5.7.5 Corrective action should take into account any existing defences and their (in)ability to achieve an acceptable level of safety risk. This may result in a review of previous safety risk assessments that may have been impacted by the corrective action. Safety risk mitigations and controls will need to be verified/audited to ensure that they are effective. Another way to monitor the effectiveness of mitigations is through the use of SPIs. See Chapter 4 for more information on safety performance management and SPIs. Chapter 2. Safety Management Fundamentals 2-17 2.5.8 Safety risk management documentation 2.5.8.1 Safety risk management activities should be documented, including any assumptions underlying the probability and severity assessment, decisions made, and any safety risk mitigation actions taken. This may be done using a spread sheet or table. Some organizations may use a database or other software where large amounts of safety data and safety information can be stored and analysed. 2.5.8.2 Maintaining a register of identified hazards minimizes the likelihood that the organization will lose sight of its known hazards. When hazards are identified, they can be compared with the known hazards in the register to see if the hazard has already been registered, and what action(s) were taken to mitigate it. Hazard registers are usually in a table format and typically include: the hazard; potential consequences; and assessment of associated risks, identification date, hazard category, short description, when or where it applies, who identified it and what measure have been put in place to mitigate the risks. 2.5.8.3 Safety risk decision-making tools and processes can be used to improve the repeatability and justification of decisions taken by organizational safety decision makers. An example of a safety risk decision aid is provided below in Figure 6. Figure 6. Safety risk management decision aid 2-18 Safety Management Manual (SMM) 2.5.9 Cost-benefit analysis Cost-benefit or cost-effectiveness analysis is normally carried out during the safety risk mitigation activities. It is commonly associated with business management, such as a regulatory impact assessment or project management processes. However, there may be situations where a safety risk assessment may have a significant financial impact. In such situations, a supplementary cost-benefit analysis or cost-effectiveness process to support the safety risk assessment may be warranted. This will ensure cost-effectiveness analysis or justification of recommended safety risk control actions has been taken into consideration, with the associated financial implications. ______________________ 3-1 Chapter 3 SAFETY CULTURE 3.1 INTRODUCTION 3.1.1 A safety culture is the natural consequence of having humans in the aviation system. Safety culture has been described as “how people behave in relation to safety and risk when no one is watching”. It is an expression of how safety is perceived, valued and prioritized by management and employees in an organization, and is reflected in the extent to which individuals and groups are: a) aware of the risks and known hazards faced by the organization and its activities; b) continuously behaving to preserve and enhance safety; c) able to access the resources required for safe operations; d) willing and able to adapt when facing safety issues; e) willing to communicate safety issues; and f) consistently assessing the safety related behaviours throughout the organization. 3.1.2 Annex 19 requires that both States and service providers promote a positive safety culture with the aim of fostering effective safety management implementation through the SSP/SMS. This chapter provides guidance on the promotion of a positive safety culture. 3.2 SAFETY CULTURE AND SAFETY MANAGEMENT 3.2.1 Whether an organization realizes it or not, it will have a number of different “safety cultures” that reflect group-level attitudes and behaviours. No two organizations are identical, and even within the same organization, different groups may have various ways of thinking about safety, talking about safety and acting on safety issues. This variation may be appropriate for different activities. 3.2.2 How safety values are incorporated into practices by management and personnel directly affects how key elements of the SSP and SMS are established and maintained. As a consequence, safety culture has a direct impact on safety performance. If someone believes that safety is not that important then workarounds, cutting corners, or making unsafe decisions or judgements may be the result, especially when the risk is perceived as low and there is no apparent consequence or danger. The safety culture of an organization therefore significantly influences how their SSP or SMS develops and how effective it becomes. Safety culture is arguably the single most important influence on the management of safety. If an organization has instituted all the safety management requirements but does not have a positive safety culture, it is likely to underperform. 3.2.3 When the organization has a positive safety culture, and this is visibly supported by upper- and middle-management, front-line personnel tend to feel a sense of shared responsibilities towards achieving the organization’s safety objectives. Effective safety management also supports efforts to drive towards an increasingly positive safety culture by increasing the visibility of management’s support and improving active involvement of personnel in managing safety risk. 3-2 Safety Management Manual (SMM) 3.2.4 A positive safety culture relies on a high degree of trust and respect between personnel and management. Time and effort are needed to build a positive safety culture, which can be easily damaged by management decisions and actions, or inactions. Continuous effort and reinforcement is needed. When leadership actively endorses safe practices, it becomes the normal way of doing things. The ideal situation is a fully implemented and effective SSP/SMS and a positive safety culture. Hence, an organization’s safety culture is often seen as a reflection of the maturity of its SSP/SMS. Effective safety management empowers a positive safety culture and a positive safety culture empowers effective safety management. 3.2.5 Safety culture and its influence on safety reporting 3.2.5.1 SSPs and SMSs are sustained by safety data and safety information that is necessary to address existing and potential safety deficiencies and hazards, including safety issues identified by personnel. The success of a reporting system depends entirely on the continuous flow of information from, and feedback to, organizations and individuals. The protection of safety data, safety information and related sources is essential to ensure continued availability of information. For example, in voluntary safety reporting systems, this may be realized through a system that is confidential, and not used for purposes other than maintaining or improving safety. The benefits are twofold. Often personnel are the closest to safety hazards, so a voluntary reporting system enables them to actively identify these hazards and suggest workable solutions. At the same time, the regulator or management is able to gather important safety information and build trust with the organizations or operational personnel who are reporting the information. For more information about the protection of safety data and safety information refer to Chapter 7. 3.2.5.2 Whether organizations or individuals are willing to report their experiences and errors is largely dependent on the perceived benefits and disadvantages associated with reporting. Safety reporting systems may be anonymous or confidential. In general, in an anonymous reporting system a reporter does not provide the identity. In this case there is no opportunity for further clarification of the report’s contents, or the ability to provide feedback. In a confidential reporting system, any identifying information about the reporter is known only to a designated custodian. If organizations and individuals who report safety issues are protected and treated in a fair and consistent manner, they are more likely to divulge such information and work with the regulator or management to effectively manage the associated safety risk(s). 3.2.5.3 States are expected to adopt laws to adhere to the provisions outlined in Annex 19 for the protection of safety data, safety information and related sources. In the case of a voluntary reporting system, confidentiality should be ensured and the reporting system operated in accordance with the safety protection laws. Further, organizations need to have an appropriate disciplinary policy, which is accessible to all and widely understood. A disciplinary policy should clearly indicate what behaviours are considered unacceptable and how the organization will respond in such cases. The disciplinary policy needs to be applied fairly, reasonably and consistently. Finally, organizations and individuals are more likely to report their experiences and errors in an environment where they will not be judged or treated unfairly by their peers or their employer. 3.2.5.4 Overall, organizations and individuals must believe they will be supported when reporting in the interest of safety. This includes organizational and personal errors and mistakes. An increase in confidential reports and a decrease in anonymous reports is usually indicative of the organization’s progress towards a positive safety culture. 3.2.6 Safety culture and cultural diversity 3.2.6.1 National culture differentiates the characteristics of particular nations, including the role of the individual within society, the manner in which authority is distributed, and national priorities with respect to resources, accountabilities, morality, objectives and legal systems. Chapter 3. Safety Culture 3-3 3.2.6.2 From a safety management perspective, national culture influences the organizational culture and plays a large part in determining the nature and scope of regulatory enforcement policies, including the relationship between regulatory authority personnel and industry personnel, and the extent to which safety information is protected. These in turn, impact on peoples’ willingness to report safety issues. 3.2.6.3 The majority of organizations today employ people from multiple cultural backgrounds, which may be defined by their nationality, ethnicity, religion, and/or gender. Aviation operations and safety rely on effective interaction between different professional groups, each with their own professional culture. Hence, the organization’s safety culture may also be significantly affected by the variety of cultural backgrounds of the members of its workforce. 3.2.6.4 Managing safety within the aviation system therefore requires interaction with, and management of, culturally diverse personnel. However, when implementing safety management, managers should be capable of moulding their culturally-diverse workforce into effective teams. Eliminating differences in safety risk perceptions that may derive from different cultural interpretations and enhancing other safety-related aspects, such as communication, leadership styles and interaction between supervisors and subordinates is key. The degree of success will depend on management’s ability to promote a common understanding of safety and each individual’s role in its effectiveness. Regardless of an individual’s cultural background, effective safety management relies on a shared safety culture, with everyone in the organization understanding how they are expected to behave in relation to safety and risk “even when no one is watching”. 3.2.7 Safety culture and organizational change Safety management requires that organizations manage the safety risks associated with organizational and operational changes. Staff concerns about workload, job security and access to training are associated with significant change in organizations and can have a negative impact on safety culture. The degree to which staff feel involved in the development of change and understand their role in the process will also influence the safety culture. 3.3 DEVELOPING A POSITIVE SAFETY CULTURE 3.3.1 A positive safety culture has the following features: a) managers and employees, individually and collectively, want to make decisions and take actions that promote safety; b) individuals and groups continually critique their behaviours and processes and welcome the critique of others searching for opportunities to change and improve as their environment changes; c) management and staff share a common awareness of the hazards and risks faced by the organization and its activities, and the need to manage risks; d) individuals act and make decisions according to a common belief that safety is part of the way they do business; e) individuals value being informed, and informing others, about safety; f) individuals trust their colleagues and managers with information about their experiences, and the reporting of errors and mistakes is encouraged to improve how things are done in the future. 3-4 Safety Management Manual (SMM) 3.3.2 Actions by management and employees can help drive their safety culture to be more positive. Table 5 provides examples of the types of management and employee actions that will enable or disable a positive safety culture in an organization. Organizations should focus on providing enablers and removing any disablers to promote and achieve a positive safety culture. Chapter 3. Safety Culture 3-5 Element General Description Enablers Disablers Commitment to safety Commitment to safety reflects the extent to which appropriate levels within the organization have a positive attitude towards safety and recognizes its importance. Senior management should be genuinely committed to achieving and maintaining a high level of safety and give employees’ motivation and the means to do so as well. • Management leads safety culture and is actively motivating its employees to care for safety, not only by talking but by acting as role models • Management provides resources for a range of safety related tasks (e.g. training) • Continuous safety management oversight and governance is established • Management is actively demonstrating that profit, cost reduction and efficiency come first • Investments to improve safety are often made when required by regulations or after accidents • Neither oversight nor governance with regards to safety management is established Adaptability Adaptability reflects the extent to which employees and the management are willing to learn from past experiences and are able to take action necessary in order to enhance the level of safety within the organization. • Employee input is actively encouraged when addressing safety issues • All incidents and audit findings are investigated and acted upon • Organizational processes and procedures are questioned for their safety impact (high extent of self-criticism) • A clear proactive approach to safety is demonstrated and followed • Employee input on safety issues is not sought from all levels of the employees • Actions are often taken only after accidents or when required by regulations • Organizational processes and procedures are considered adequate as long as no accident occurs (complacency or lack of self-criticism) • Even when an accident occurs the organization is unwilling to question itself. • A reactive approach to safety is demonstrated and followed. Awareness Awareness reflects the extent to which employees and management are aware of the aviation risks faced by the organization and its activities. From a State perspective personnel are aware of both the safety risks induced by their own activities and the organizations they oversee. Employees and management should be constantly maintaining a high degree of vigilance with respect to safety issues. • An effective way of hazard identification has been established • Investigations seek to establish the root cause • The organization stays abreast of important safety improvements, and adapts itself accordingly as necessary • The organization systematically evaluates if safety improvements are implemented and working as intended • Where appropriate members of the organization are well aware of the safety risks induced by their individual actions and company operations / activities • No effort is spent on hazard identification • Investigations stop at the first viable cause rather than seek the root cause • The organization does not stay abreast of important safety improvements • The organization does not evaluate if safety improvements are implemented properly • Where appropriate members of the organization are not aware of the safety risks induced by their individual actions and company operations • Safety data is gathered but not analysed and acted upon 3-6 Safety Management Manual (SMM) Element General Description Enablers Disablers Behaviour with respect to safety Behaviour with respect to safety reflects the extent to which every level of the organization behaves such as to maintain and improve the level of safety. The importance of safety should be recognized and processes and procedures needed to maintain it should be put in place. • The employees motivate themselves to act safely and by acting as role models • Continuous monitoring of safe behaviour is practised • Intentional unsafe behaviour is not tolerated by management and colleagues • The working conditions support aviation safety at all times • Employees are not punished for intentional unsafe behaviour to the benefits of their own or other interests • The working conditions provoke behaviour and work-arounds that are detrimental to aviation safety • No monitoring of aviation safety within the organization’s products or services is practised • Constructive criticism to the benefit of aviation safety is not welcomed Information Information reflects the extent to which information is distributed to all necessary people within the organization. Employees should be enabled and encouraged to report aviation safety concerns and receive feedback on their reports. Work information related to aviation safety has to be communicated meaningfully to the right people in order to avoid miscommunication that could lead to hazardous aviation system situations and consequences. The State is open to share aviation safety related information to all service providers. • An open and just safety-reporting environment exists. • Employees are provided with safety-relevant information in a timely manner in order to allow for safe operations or decisions to be made. • Management and supervisors regularly check whether safety-relevant information is understood and acted upon • Knowledge transfer and training with regards to aviation safety is actively practiced (e.g. sharing of lessons learned) • A blaming safety reporting environment is evident • Safety relevant information is withheld • Safety communication is not monitored for its effectiveness • No knowledge transfer or training is provided Trust Employees contribution to safety thrives in a reporting environment that fosters trust - trust that their actions or omissions, commensurate with their training and experience, will not be punished. A workable approach is to apply a reasonableness test – i.e. is it reasonable that a person with the same level of experience and training might do the same thing. Such an environment is fundamental to effective and efficient safety reporting. Effective safety reporting systems help to ensure that people are willing to report their errors and experiences, so that States and service providers have access to relevant data and information that is necessary to address existing and potential safety deficiencies and hazards. Creating an environment in which people can be confident that safety data and safety information will be used exclusively for improving safety. • There is a distinction between acceptable and unacceptable behaviour, which is known to all employees. • Occurrences (including accidents and incidents) investigations consider individual as well as organizational factors. • Good aviation safety performance is recognized and rewarded on a regular basis. • There is willingness among employees and operational personnel to report events in which they have been involved. • There is no identifiable distinction between acceptable and unacceptable behaviour. • Employees are systematically and rigorously punished for human errors. • Accident and occurrence investigations focus on individual factors only. • Good safety performance and safe behaviour is taken for granted. Table 5. Examples of actions that will enable or disable a positive safety culture Chapter 3. Safety Culture 3-7 3.3.3 Monitoring safety culture 3.3.3.1 Safety culture is subject to many influences and organizations may choose to assess their safety culture to: a) understand how people feel about the organization and how importantly safety is perceived; b) identify strengths and weaknesses; c) identify differences between various groups (subcultures) within an organization; and d) examine changes over time (e.g. in response to significant organizational changes such as following an accident, a change in senior management or altered industrial relations arrangement). 3.3.3.2 There are a number of tools which are used to assess safety culture maturity, usually in combination: a) questionnaires; b) interviews and focus groups; c) observations; and d) document reviews. 3.3.3.3 Assessing the safety culture maturity can provide valuable insight, leading to actions by management that will encourage the desired safety behaviours. It should be noted that there is a degree of subjectivity with such assessments and may reflect the views and perceptions of the people involved at a particular moment only. Also, scoring safety culture maturity can have unintended consequences by inadvertently encouraging the organization to strive to achieve the “right” score, rather than working together to understand and improve the safety culture. _____________________ Next >