A Safety Culture makes a difference

1. Safety Culture
What it is and
the Six steps Necessary to Achieve it
Presented by
Gordon Dupont
Presented at
Flight Safety Foundation
Business Aviation Safety Summit
Montreal, PQ April 11, 2013

2. Safety Culture
Is a lot more than a sign
Safety First
Unless it costs money
Unless it costs money
Unless it costs money
it costs money

3. What is Safety?
• The state of being Safe
• The condition of being Safe
from undergoing or causing
hurt, injury or loss
Webster’s Dictionary
• The risk (odds) of something causing you grief is
As Low As Reasonably Practical (ALARP)
G. Dupont

4. What is a Safety Culture?
Safety is treated seriously by the management and all
employees
Safety goals are set and all work toward their
achievement
all company employees are trained and encouraged to
think and work Safely at all times
a system is in place to report Safety concerns
all believe that Safety does not have to come at the cost
of productivity or profit
Safety is an integral part of the way the company
operates
The company has a framework to accomplish all of the
above –A Safety Management System (SMS)
Gordon Dupont
It is a Culture where:

5. Why is a Safety Culture so
important now?
The probability (risk) of being killed in an aircraft
accident varies from
1 in 260,000 (Africa)
To
1 in 11,000,000 (45 million 2012 USA)
A difference of 42 times better Why?
A Safety Culture makes a difference

6. Hull loss accident rate
Airline Aircraft in service
12,595
1997
Millions of departures
Hull loss
accidents
per year
1965 1975 1985 1995 2005 2015
Year
50
45
40
35
30
25
20
15
10
5
0
Boeing Aircraft Corporation
25,598
2016
Major Fatal Airline Accidents per year
By 2016 there will be one major fatal accident
per week somewhere in the world
We must
continue to
do better

7. You’ll Know it
When You Work in it
• It is very difficult to measure accurately
• It is seen by the way things are done around
the organization
• It is heavily influenced by management
• It is constantly changing
What does a Safety Culture look like?

8. A Safety Culture must have
the 3 “C’s”
C
C
C
ommitment
ompetence
ognizance
Mintzberg
Management’s True motivation and allocation of resources
Knowledge to know how to achieve the
organization’s Safety goals
Awareness that it is a never
ending battle

9. The Six Steps to a
Safety Culture
1. JUST culture
James Reason
Gordon Dupont

10. Step 1 A Just Culture
• A Just Culture is the foundation of
any Safety Culture
• Where “Honest & At-Risk”
mistakes do not result in discipline
• Where an Administrative policy
spells out “Reckless Behaviour”
• Where persons can admit to an
error without fear of punishment
Screw up and
you’re history

11. But what about Discipline?
• What is the real purpose of
discipline?
TO BE SEEN TO BE DOING
SOMETHING?
TRADITION?
To ensure an occurrence
does not happen again
• REVENGE?
Holding the Person Accountable

12. If only they all wore hats

13.  Was the act deliberate with a reasonable
knowledge of the possible consequences?
 Has the person made similar errors in the past?
 Do they accept responsibility for their actions?
Degree of Discipline
X
X
X

14.  Was the act deliberate with a reasonable
knowledge of the possible consequences?
 Has the person made similar errors in the past?
 Do they accept responsibility for their actions?
 Has the person learned from the experience?
 Are they likely to do it again?
Degree of Discipline
X
X
X
X
X

15. Anyone can make a
mistake
but
only a fool
(company or individual)
makes the
same mistake twice

16.  Was the act deliberate with a reasonable
knowledge of the possible consequences?
 Has the person made similar errors in the past?
 Do they accept responsibility for their actions?
 Has the person learned from the experience?
 Are they likely to do it again?
Degree of Discipline
X
X
X
X
X
Remember the reason for Discipline
To Ensure It Does Not Happen Again

17. Discipline – To Ensure That It Does Not Happen Again
• No hull insurance
• Wife severely injured
• Pilot severely injured
• Off work for a month
He was found
NOT GUILTY

18. James Reason
Gordon Dupont
1. JUST culture
SAFETY culture
2. TRUSTING culture (G. Dupont)

19. Levels of Trust
Low
High
High
Cooperation
Trust
Defensive – Us vs. Them (Lose Lose)
Respectful - Compromise
(Win Lose – Lose Win)
Synergistic - WE can
solve the problem
(Win Win)
Step 2 A Trusting Culture

20. James Reason
Gordon Dupont
1. JUST culture
3. REPORTING culture
SAFETY culture
2. TRUSTING culture (G. Dupont)

21. provides the means to capture the
lessons to be learned arising from
human errors, near misses
or free lessons
Step 3 A Reporting Culture
You can’t fix what you don’t know

22. •Interview Responsible
Personnel
• Find Contributing
Factors
• Get Ideas for Process
Improvement
MEDA (Maintenance Error Decision Aid) Objectives
Event
Occurs
• Many Current Error Investigation Processes
Investigation
Reveals Event
Caused by
Maintenance
Error
Determine
Who Made
Error
Administer
Discipline
Event
Occurs
• The MEDA Process
Investigation
Reveals Event
Caused by
Maintenance
Error
Determine
Who Made
Error
Follow-up to
Obtain
Additional
Contributing
Factors and
Information
Add to
Maintenance
Error Data
Base
Make Process Improvements
Based on Contributing Factors
•Based on This Event
•Based on Analysis of Data
for Multiple Events
Provide Feedback
to All Employees
Affected by
Process
Improvements

23. Don’t Sweat the Small Stuff
And You Will Avoid Having to
Sweat the Big Stuff
This is what SMS is all about
The Small Stuff has the potential
to become the Big Stuff
Gordon Dupont
For Example

25. James Reason
Gordon Dupont
1. JUST culture
4. LEARNING culture
3. REPORTING culture
SAFETY culture
2. TRUSTING culture (G. Dupont)

26. Enables us to take the reports with their “Free lessons”
and through Risk Management lower the hazards that
threaten the Safety of the organization
Enables us to analyze what we weren’t even aware of
before
We are able to fix the problem (Hazard) before it
causes an accident
Takes us from the Reactive level to the Proactive level
Step 4. A Learning Culture

27. Step 4 A Learning Culture
• Where human factors training is
provided to all on an ongoing basis
• Where incident data is kept and analyzed to
find trends and develop Safety nets
• Where major changes are carried out when
the present system is not sufficiently Safe
• Where feedback is provided as a means of
learning from all incidents

28. James Reason
Gordon Dupont
1. JUST culture
5. INFORMED culture
4. LEARNING culture
3. REPORTING culture
2. TRUSTING culture (G. Dupont)
SAFETY culture

29. Step 5 An Informed Culture
1. A Mission Statement - Posted
Where everyone knows
the organization’s true
Safety commitment

30. A Mission Statement
That Everyone Knows

31. Step 5 An Informed Culture
1. A Mission Statement - Posted
2. A Safety Policy - Posted
Where everyone knows
the organization’s true
Safety commitment

32. Management
Managers and supervisors
Managers and supervisors
Supervisors
Supervisory
Employee
Employee
Everyone

33. This is an excellent one

34. Step 5 An Informed Culture
3. An Administrative Policy – Known by all
4. Long term Safety goals – Known by all who
work toward them
5. Optional - Core Values Statement - Posted
Where everyone knows
the organization’s true
Safety commitment
1.A Mission Statement - Posted
2.A Safety Policy - Posted

35. James Reason
Gordon Dupont
1. JUST culture
5. INFORMED culture
4. LEARNING culture
3. REPORTING culture
2. TRUSTING culture (G. Dupont)
SAFETY culture
6. FLEXIBLE culture

36. Step 6 A Flexible Culture
• Where necessary changes are
made in order to improve Safety
• Where the organization is
constantly looking for better ways to work Safer
• Where the status quo is not considered an option in
the quest to lower errors
• Where there is a “Chronic Unease” that in spite of
all efforts, human error will still occur
• Where an Emergency Response Plan (ERP) is in
place in the event of an error occurring

37. James Reason
Gordon Dupont
1. JUST culture
5. INFORMED culture
4. LEARNING culture
3. REPORTING culture
2. TRUSTING culture (G. Dupont)
SAFETY culture
6. FLEXIBLE culture

38. Thank You
for the Opportunity to Provide this Message
Gordon Dupont

39. What Class of Error?
Honest, At-Risk, Reckless

40. How do we measure this?