A Shift In Safety Thinking

Transcription

1 Human Behavior Safety Management Series A Shift In Safety Thinking Zero Violations is the new standard Presented by: Jim Hein, ASI-FPM-MAS Presented to: NBAA IA Renewal October 21, 2013

2 Reasons for this presentation: Promote a generative safety culture. Promote a zero violation climate Promote a Reporting Culture 2

3 Human Behavior Safety Management Series The Safety Concept

4 Concept of safety What is safety Zero accidents (or serious incidents)? Freedom from danger or risks? Error avoidance Regulatory compliance?? 4

5 Concept of safety Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through Risk level a continuing process of hazard identification, risk Acceptable risk level management and use of established safety Established safety controls controls. Ref: ICAO Doc

6 Concept of safety Combination of hazard consequences and frequency Risk level is unknown until hazards are analyzed Risk level Level established by the organization Done by a documented methodical process Acceptable risk level Established safety controls Policies, procedures, regulations, best practices Ref: ICAO Doc

7 Controls are mitigation strategies designed to reduce risk when human factors negatively combine with what we are doing. Policies Procedures Rules Regulations Best Practices 7

8 Human Behavior Safety Management Series History of Safety-Think

9 The evolution of safety thinking 1950s 1970s 1990s 2000s TECHNICAL FACTORS Manufacturing, Operations, Maintenance, Design HUMAN FACTORS Human Failures ORGANIZATIONAL FACTORS Management, supervision, company policies CULTURAL FACTORS Behavioral Failures TODAY TODAY TODAY TODAY 9

10 Human Behavior Safety Management Series Culture Traits

11 Distinct culture sources National culture encompasses the value system of particular nations. Organizational/corporate culture differentiates the values and behaviours of particular organizations (e.g. government vs. private organizations). Professional No human culture endeavour differentiates is culture-free the values and behaviours of particular professional groups (e.g. pilots, air traffic controllers, maintenance engineers, aerodrome staff, etc.). Personal culture. Differentiates the values and behaviours of each individual for any given circumstance. 11

12 Organizational/corporate culture Sets the boundaries for acceptable behaviour in the workplace by establishing limits. Establishes acceptable risk levels. Provides a frame work for managerial and employee decision-making Shapes acceptable procedures and practices. 12

13 Organizational Culture Attributes: Pathological Bureaucratic Generative Information Hidden Ignored Sought Messengers Shouted Tolerated Trained Responsibilities Shirked Boxed Shared Reports Discouraged Allowed Rewarded Failures Covered up Merciful Scrutinized New ideas Crushed Problematic Welcomed Resulting organization Conflicted organization Red tape organization Reliable organization Source: Ron Westrum 13

14 Range of organizational cultures GENERATIVE safety is how we do business round here Increasingly informed PROACTIVE we work on the problems that we still find CALCULATIVE we have systems in place to manage all hazards REACTIVE Safety is important, we do a lot every time we have an accident Increasing Trust PATHOLOGICAL who cares as long as we re not caught 14

15 Culture Summary CULTURE TYPES National Organizational Professional Personal CULTURE TRAITS Pathological Bureaucratic Proactive Generative GENERATIVE CULTURE TRAITS Just Flexible Willing Learning Accountable Reporting 15

16 Personal culture Must comply with the limits established for acceptable behaviour in the workplace. Must protect acceptable risk levels. Must believe in, support and utilize safety reporting procedures and practices set by the Organizational culture. Can highly influence behaviours within the organizational culture (positively and negatively). 16

17 Human Behavior Safety Management Series Errors Mistakes and Lapses

18 Understanding human error Competent people commit errors. Errors are normal where humans and technology interact. Human error is a contributing finding in aviation occurrence investigations. Risk reduction strategies protect when human errors occur. Controls are mitigation strategies designed to reduce risk when human factors negatively combine with what we are doing. 18

19 Human Behavior Safety Management Series Violations vs Mistakes

20 Violation Definition Violations are deliberate and intentional deviations from policies, rules, procedures, instructions, regulations, and best practices developed to promote acceptable risk levels and efficient operations. 20

21 Violation Definition This should not be confused with the human condition of making mistakes. Human errors, mistakes and violations all result in non-compliance The difference is that violations are preventable. 21

22 Violation space Exceptional violation space Understanding violations: High Acceptable risk level Accident Incident System s production objective(s) Risk Low Minimum Safety space System output Maximum 22

23 Rationalizations for Violation Expectation Rule must be bent to get the job done Powerfulness Ability, Experience, Judgement Opportunities Optimization, Short cuts, Better, Quicker Planning Poor advance preparation, working on the fly Patrick T.W. Hudson, D. Parker, R. Lawton, (2005) 23

24 Why are Violations Dangerous? Violators assume they re the only one Violators don t tell anyone what they are doing Violations Increase risk levels to unacceptable Errors (slips, lapses, mistakes) are independent of intention Violations combine with human errors to create unacceptable or dangerous circumstances. Violation + Error = Death/Doom/Disaster Managing Maintenance Error, James Reasons and Alan Hobbs 24

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26 Human Behavior Safety Management Tools for better safety cultures

27 Tools currently available Management Training SMS Training (SRM- SA) Root Cause Analysis Training LOSA HF Training Employee Reporting 27

28 Effective safety reporting Five traits Information People are knowledgeable about the human, technical and organizational factors that determine the safety of the system as a whole. Willingness People are willing to report their errors and experiences. Accountability Effective safety reporting People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that differentiates between acceptable and unacceptable behaviour. Flexibility People can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing information to quickly reach the appropriate decisionmaking level. Learning People have the competence to draw conclusions from safety information systems and the will to implement major reforms.

29 Human Behavior Safety Management Series Barriers to a Zero Violation Safety Climate

30 # 1 Barrier to ZV success Resistance and Fear* People are afraid of unknown Expectations based on past experience Desire to test the system Looking for WIIFM Fear of losing job Fear of being outside of comfort zone Fear of being out of control Perceived as a turf battle Feeling of inadequacy Lack of experience Lack of sufficient skills Lack of management sponsorship * Change Management, Chad Van Zandt,

31 Change Resistance Antidotes: Training Coaching Support Reinforcement Communications Set Zero Violations as the minimum STANDARD * Change Management, Chad Van Zandt,

32 Human Behavior Safety Management Series Call to Action Now is the time for a safety-think shift Begin by making Zero Violations The Standard

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34 Questions??? 34

35 FAASafety.gov We Need Your Help

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