Just Culture for safety performance (can it work across national cultures?) Keven Baines Director 25 th March 2015 CHC Safety Summit

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2 (can it work across national cultures?) Keven Baines Director 25 th March 2015 CHC Safety Summit

3 Workshop flow 1. Just Culture why? 2. What is it? 3. How to build one? 4. Does it deliver/work across national cultures? 3

4 Just Culture why? a proactive safety culture that is founded upon a Just Culture being Just - the bedrock of safety performance encourages openness and proactive reporting of hazards enables you to discover what people have to do to get the job done facilitates Risk Based Decision Making 4

5 How did Just Culture evolve? Blame and Train Culture No Blame Culture Just Culture 5

6 Just Culture the key Safety Performance enabler A Proactive Culture is the bedrock of safety performance. A Proactive Safety Culture encompasses an organisation s commonly held perceptions and beliefs regarding safety and has the potential to significantly influence people s behaviour. A Proactive Safety Culture is founded upon a Just Culture in which individuals freely and openly share safety-related information in an atmosphere of trust, born from a sense of justice.

7 What are the benefits of Just Culture? Just Culture Confidence in being treated fairly and feeling able to change something Reporting Information Risks Improved (risk based) decision making

8 Regulatory context New European regulation on mandatory occurrence reporting (No.376/2104) in force from November 2015 Each organisation established in a Member State shall.. adopt internal rules describing how just culture principles... are guaranteed and implemented within that organisation. 8

9 Definition of Just Culture A culture that recognizes that competent professionals make errors and acknowledges that even competent professionals will develop unhealthy norms (shortcuts, routine rule violations), but has zero tolerance for reckless behaviour

10 It s part of the human condition to err The Human Reliability Curve 100% Human Error The Error Zone Human Reliability Normal Operation 0% Performance Influencing Factors (PIFs) 10

11 Types of error Because I didn t quite do what I wanted to do: error (slip) Because I forgot or wasn t concentrating: error (lapse) Because I made the wrong decision or plan: mistake 11

12 Why are rules intentionally broken? Because there is no other choice to get the job done: situational violation Because this situation has never been imagined: exceptional violation Because it s what we do here: violation for organisational gain Cant, don't, won t 12

13 Were the rules intentionally broken?

14 Thanks, but we already have a Just Culture Can YOU find it? Can YOU explain it? Defined Understood Just Culture Demonstrated Applied Do YOU role model it? Do YOU follow the process?

15 Just Culture Self assessment Client s average score 43% 15

16 It can be measured? 16

17 Company 1 - safety culture diagnostic

18 Company 2 - safety culture diagnostic

19 Workshop flow 1. Just Culture why? 2. What is it? 3. How to build one? 4. Does it deliver/work across national cultures? 19

20 Just Culture How? Just culture assessment Safety culture diagnostic Safety vision Policies Procedures Investigation process Just Culture toolkit Competence devt Coaching Promotion Education Assurance Metrics Balanced scorecard Safety culture diagnostic... Where are we now? What do we need to put in place? How do we energise our staff? How do we sustain our culture? How do we know it is working? Understand Build Power-up Perform

21 Error Management System Threats and or CFs Hazards and or PIFs Unsafe Act (Error/Mistake/Violation) Event (Unwanted Harm) Pro Active Hazard/Near-Miss/Error/Mistake/Violation Reporting Reactive Occurrence Reporting Investigations Just Culture toolkit - inc. Event Review Group Interventions Feedback & Promotion to Develop a Learning Safety Culture Data Exploitation to make human-in-thesystem risk based decisions

22 FAiR - what is it..? a behaviour-based system for creating and sustaining a Just Culture to enable an organisation to ensure that interventions consider the Human In The System (HITS)...treating all in a fair and importantly - a consistent manner Identify effective interventions Ensure personal accountability is balanced with the desire for learning and improvement Focus on actions and intentions rather than consequences Cross cultural commonality.

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24 Event Review Group responsibilities To ensure a Human Factors-centric investigation and report is complete identifying the root cause contributing factors Ensuring all the Why did it happen? questions have been answered To ensure effective interventions are put in place following an event To determine any potential accountability. 24

25 Typical Event Review Group composition SMS Manager Trained ERG members (an uneven number if possible) Subject Matter Experts (as required) To minimise bias and preserve impartiality the Manager of the area in which the event has occurred should not be part of the ERG or take part in the related ERG decision(s). 25

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28 Workshop flow 1. Just Culture why? 2. What is it? 3. How to build one? 4. Does it deliver/work across national cultures? 28

29 Just Culture - does it really deliver? We are now undertaking activity that would normally only have resulted from an accident, but in this case, no-one was hurt and nothing was damaged. The last three weeks have seen some of the most valuable people-centred safety management activity we have conducted. Group Captain Gale, Commanding Officer RAF Lossimouth We are learning things about ourselves that we normally only learn after a funeral and the loss of jet Senior Engineering Manager - military aviation I'm stunned by what s been culturally acceptable and what I'm learning. We are now motivated to do and learn more. Director of Operations major International Airline I m shocked and I m depressed, but at least I know where we are now...plotting the course to point B has been made easier Senior Manager major aircraft manufacturer

30 Lastly, please remember FAiR has been designed to offer a handrail to aid organisations Meant to assist organisations practical apply sound Human Factors theory, especially in the area of matching behaviours to interventions It is absolutely dependent on: a structured process leadership buy-in and the competence of individuals using it.

31 Conclusion a proactive safety culture that is founded upon a Just Culture being Just - the bedrock of safety performance encourages openness and proactive reporting of hazards enables you to discover what people have to do to get the job done facilitates Risk Based Decision Making If commonly applied will be successful across international businesses. 31

32 Date for your diary 32

33 Safety Performance through 33