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Safety Culture Definitions and Enhancement Process


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Safety Culture Definitions and Enhancement Process

  1. 1. Reprinted July 2012Safety CultureDefinition andEnhancementProcess
  2. 2. Safety Culture Definition Contentsand Enhancement Process 1_ Background_p3 2_ Safety Culture Definition and Elements_p3 2.1_ Proposed Safety Culture Definition_p3 2.2_ Safety Culture versus Safety Climate_p3 2.3_ Proposed Safety Culture Elements_p43_ Systematic Safety Culture Enhancement Process_p6 3.1_ Define the Safety Culture_p7 3.2_Identify Drivers of a Safety Culture_p8 3.3_Measuring the Safety Culture_p9 3.4_Evaluating the Measures_p10 3.5_Improving the Safety Culture_p103_ Conclusions_p11© Copyright CANSO 2008. All rights reserved. No part of this publicationmay be reproduced, or transmitted in any form, without the priorpermission of CANSO.This document has been developed through the collective contributionsof CANSO members. The views and recommendations expressed in thispublication do not necessarily reflect those of individual CANSO members.We have endeavoured to ensure the integrity of this publication insofaras possible. However, please note that the responsibility for the quality,accuracy, and verification of the data and results in this report rests withparticipating ANSPs. All recommendations are made without any warrantyor guarantee on the part of the contributors or CANSO. CANSO disclaimsany liability in connection with the use of this publication or any aspectthereof.
  3. 3. Safety Culture Definition 2_3and Enhancement Process1Background The detailed work plan for Year One for address the fact that a safety culture isthe CANSO Safety Culture Workgroup (CSCWG) demonstrated through attitudes, accepted normsidentified a number of activities. Two key and behaviours. It is about how things work anddeliverables for the year are: “the way things are done around here.” Finally, the safety culture definition should 1. CANSO Safety Culture Definition be related directly to the safe provision of air 2. Safety Culture Enhancement Process navigation. On the other hand, it should not include Model worker safety which comes under the purview of occupational health and safety, which is not This document was prepared by the CANSO in the scope of the CSCWG. However, it can beSafety Culture Workgroup. It presents a proposal assumed, that a good safety culture focused onfor the above deliverables for review, comment service provision also has a positive effect onand acceptance by the CANSO Safety Standing occupational health and safety.Committee (SSC). Based on the review, further discussion and the elements presented above, a safety culture2 definition for use by CANSO was developed. TheSafety Culture Definition and Elements proposed definition is: “Safety culture refers to the enduring value,2.1_Proposed Safety Culture Definition priority and commitment placed on safety by every A review of a number of definitions of safety individual and every group at every level of theculture was conducted by the CSCWG. This review organisation. Safety culture reflects the individual,included identifying the strengths and weaknesses group and organisational attitudes, norms andof each definition. behaviours related to the safe provision of air The review identified a number of elements navigation services.”necessary for a good safety culture definition.First and foremost the definition should recognise 2.2_Safety Culture versus Safety Climatethat a safety culture reflects individual, group and One of the issues highlighted in the literatureorganisational attitudes, norms and behaviours. is the lack of universal consensus regarding theSafety culture is not just a reflection of the individuals terms safety culture and safety climate. Muchthat make up an organisation; an organisation’s debate still continues over the definition andsafety culture is more than the sum of its parts. application of the terms and they are often used Secondly, a safety culture definition must interchangeably. For the purpose of CANSO andrecognise that safety culture is reflected in the its related safety culture work, there will be avalue of, priority of and commitment to safety. An distinction between the two terms.organisation with a strong safety culture values Safety Culture has been defined abovethe importance of safety; it recognises that safety and is seen as representing the more enduring,is a business imperative. Safety is also afforded underlying culture surrounding safety in anthe highest priority over commercial, operating, organisation whereas safety climate representsenvironmental and social pressures. And finally, what people feel and their perceptions aboutthere is a commitment to safety; safety issues safety at a given point in time. There safetyreceive the attention warranted by their significance. climate measurement provides a snap-shot of A safety culture definition should also
  4. 4. Reprinted July 2012the state of an organisation’s safety. Typically 2.3_Proposed Safety Culture Elementsthe safety climate is measured using quantitative As well as a definition, the CSCWG isquestionnaires while assessing safety culture proposing that safety culture may be furtherrequires more qualitative methods. defined by eight key elements: Informed Culture, As presented by Cox and Cox (1996), safety Reporting Culture, Just Culture, Learning Culture,culture can be likened to personality, whereas Flexible Culture, Risk Perception, Attitudes toclimate is likened to mood. Both can change within Safety and Safety-Related Behaviour. Thesean organisation. However, like one’s personality, elements were chosen as they reflect work bysafety culture takes time to grow and change; you James Reason and add three elements that werecan not “implement” a safety culture but it can be identified previously by the CANSO safety culturere-directed through concerted effort and action working group (see Figure 1). Table 1 (see pageby an organisation. Safety climate, as with one’s 5) presents the definition and an explanation ofmood, can change more quickly and dramatically each element. It is important to note that theregiven the circumstances and current conditions are interrelationships between the elements. Forbeing faced by an organisation and the resulting example, an informed culture must relay on a goodactions taken. You try to shape the culture over reporting culture, which it turn depends upon atime by changing the climate. just culture. Not only must the interrelationship between the elements be considered but the role of management in establishing the policies, procedures and tools to foster those elements and committing to their success. With these, an organisation can achieve a strong, positive safety culture. Figure 1 Elements of a Safety Culture Safety Risk Related Perception Behavior Attitudes to Safety
  5. 5. Safety Culture Definition 4_5and Enhancement Process Element Description Explanation Just Culture An atmosphere of trust in which An informed culture relies on a reporting culture which in turn people are encouraged for relies on a Just Culture. All employees must clearly understand providing essential safety-related and recognise that it is unacceptable to punish all errors and information, but in which they unsafe acts regardless of their origins and circumstances are also clear about where the while it is equally unacceptable to give blanket immunity line must be drawn between from sanctions to all actions that could, or did, contribute acceptable and unacceptable to organisational accidents. A prerequisite for engineering a behaviour. just culture is an agreed set of principles for drawing the line between acceptable and unacceptable actions. Reporting Managers and operational The issue is not whether the organisation has a reporting Culture personnel freely share critical system; it is whether, as a matter of practice, errors, near safety information without the misses, hazards and risks are reported. A reporting culture threat of punitive action. depends, in turn, on how the organisation handles blame and punishment. If blame is the routine response to error, then reports will not be forthcoming. If, on the other hand, blame is reserved for truly egregious behaviour, involving recklessness or malice, reporting in general will not be discouraged. Rather than a blanket no-blame approach, what is required, Reason argues, is a just culture. Informed Those who manage and operate Management fosters a culture where people understand Culture the system have current the hazards and risks inherent in their areas of operation. knowledge about the human, Personnel are provided with the necessary knowledge, skills technical, organisational and and job experience to work safely, and they are encouraged environmental factors that to identify the threats to safety and to seek the changes determine the safety of the necessary to overcome them. An informed culture relies on system as a whole. having a strong reporting culture. Learning An organisation must possess the Reports are only effective if an organisation learns from them. Culture willingness and the competence Learning will occur from both reactive and proactive safety to draw the right conclusions assessments and is promoted by an inherent organisational from its safety information system willingness to adapt and improve. and the will to implement major reforms. Flexible A culture in which an organisation A culture of safety is flexible, in the sense that decision- Culture is able to reconfigure themselves making processes vary, depending on the urgency of the in the face of high tempo decision and the expertise of the people involved. operations or certain kinds of danger – often shifting from the conventional hierarchical mode to a flatter mode. Risk Individuals at all organisational It has been found that misperceptions of the seriousness of Perception levels need to have the same risks occur frequently at all levels in an organisation (HSC, perceptions and judgments of 1993). The perception of risk or people’s judgments of the seriousness of risks, as these riskiness is influenced by different attributes of hazards, e.g. perceptions affect risk behaviour controllable-uncontrollable. Misjudgements of risks may and appropriate decisions with cause risk behaviour and inappropriate decisions with regard regard to safety issues. to safety measures and ordinary occupational accidents as well as large-scale accidents (Rundmo, T., 1997. Associations between risk perception and safety. Safety Science 24 (3), 197-209). Attitudes to Attitudes (especially Research has shown that attitudes to safety can be associated Safety management’s) in relation to with risk perception and safety-related behaviours. safety, risk and production. Safety- Safety-related behaviour has Having accurate risk perceptions does not necessarily result related to do with directly complying in correct risk and safety related behaviours. Ignorance or behaviour with procedures, rules and deliberate violations to safety rules and procedures are often regulations, but also to aspects due to employee attitudes towards risk and safety (HSC, such as coaching, recognising, 1993). Hale (2003) advances the shared purpose in safety communicating, demonstrating, performance, i.e. the involvement felt by all parties in the and actively caring. organisation, especially the workforce, in the process of defining, prioritising and controlling risk.
  6. 6. Reprinted July 20123Systematic Safety Culture Enhancement Process Once it has been decided to enhance an What was going to be measured was defined inorganisation’s safety culture, a systematic, closed- the first step; next, how, who, and when must beloop process for doing so must be selected. determined.A typical enhancement process is presented Once the measurement activities havein Figure 2. First and foremost, what is meant been completed, the results must be safety culture in your organisation must be Interpreting the results can be challenging and theunderstood. How will safety culture be defined? results need to have credibility both internally andWhat will be the sub-components? What will be externally.the characteristics? Before something can be After the evaluation has been completedmeasured, you must first define and describe what and interpreted, an action plan needs to beit is that you want to measure. developed to address any identified weaknesses. The next step involves identifying the drivers The enhancement process then repeats itself inof safety culture. If you know who or what drives due time, in order to check the new level of safetyculture then you are in a better position to know culture reached and to confirm if the actions takenwho or what you can elicit to help change or have been effective providing measures over time.maintain it. It is important to note that safety culture measures The third step involves measuring the safety are but one metric that can be used to evaluateculture. Tools and process must be selected the “safety state” of an organisation and in orderthat best meet the organisation’s requirements. to obtain a full picture other safety performance measures should be established. Figure 2 Systematic Safety Culture Enhancement Process { { { }
  7. 7. Safety Culture Definition 6_7and Enhancement Process3.1_Define the Safety Culture In order to determine what you are going to aspect here is management’s commitment toassess and to select the appropriate measurement safety – Is there an understanding and acceptancetools, it is first necessary to determine what of the current safety state? Is safety affordedapproach you will use to model your safety the right priority? Are the appropriate resourcesculture. A useful framework based on the work assigned to safety?by M.D. Cooper is to distinguish between three The situational aspects of safety cultureinterrelated aspects of safety culture (see Figure 3). describe ‘what the organisation has’. This is The psychological aspects of safety reflected in the organisation’s policies, operatingculture refers to ‘how people feel’ about procedures, management systems, controlsafety and safety management systems. This systems, communication flows and workflowencompasses the individual and group values, systems. These aspects can also be described asattitudes and perceptions regarding safety, which “organisational factors”.is often referred to as the safety climate of the The connecting arrows between the boxesorganisation. reflect the view that the three aspects of safety culture are interrelated and are therefore not Behavioural aspects are concerned with mutually exclusive. It is important to note that‘what people do’ within the organisation, which when looking at the different aspects one mustincludes the safety-related activities, actions and not only look at the “what or how” but also thebehaviours exhibited by employees. A critical “why”. Without understanding why people Figure 3 Safety Culture Framework
  8. 8. Reprinted July 2012feel they way they do or why they do what they do 3.2_Identify Drivers of a Safety Cultureor why the organisation has what it does, changes Cultural drivers focus on two main areasimplemented to improve culture may not address – organisational and those which relate to ‘keythe underlying issues and therefore will likely be individuals’. Organisational drivers may beinappropriate and/or ineffective. characterised by management systems and A model such as the illustrated in Figure 3 procedures in a variety of areas of organisationalwill prove useful when the time comes to select activity. These drivers include both internalthe safety culture assessment tool you will use. and external influences. Examples include: One can find in literature many suggestions corporate business plan, corporate safetyas to how best to define safety culture along with plan, organisational systems, procedures andthe key characteristics or indicators as illustrated standards. External examples include: regulatoryin Figure 4. Reason breaks safety culture down and legal requirements as well as industryinto five elements – Reporting, Just, Flexible, standards.Learning and Informed. Ron Westrum and Mark Key groups and individuals within anFlemming have identified lower level indicators organisation can influence and drive culturewhich can be, in some instances, mapped directly both directly and indirectly through their actions,into Reason’s elements. It is necessary to select words and commitment. There can be a strongand define the indicators that will be used to relationship and influence between groupmeasure safety culture before selecting the behaviours and individual drivers. Groups withinmethods and tools that will be employed. an organisation can be professional groups, Figure 4 Indicators of a Safety Culture
  9. 9. Safety Culture Definition 8_9and Enhancement Processlabour groups. Just some of the many possible define safety culture and its key indicators.individual drivers include the CEO, Senior These tools and frameworks allowmanagement, safety personnel, “champions” and organisations to determine the extent to whichof course the employees themselves. the indicators of a strong safety culture exist in Knowing the key drivers will be important an organisation and/or have been instilled in thewhen it comes to evaluating any measurement behaviours of managers and employees.results and planning safety culture enhancement The selection of the tool or tools that will bestrategies. An organisation can use these drivers to used depends upon a number of factors, includingdevelop and implement strategies for improving its what will be measured, resources and culture. Going back to our model of a safety culture (See Figure 5), you can see that different tools are used3.3_Measuring the Safety Culture depending upon which aspects of a safety culture There are many tools that have been you want to assess. For example, questionnairesdeveloped to measure the various aspects of can be used to assess the psychological orsafety culture. Some focus only on operational behavioural aspects. It is important to realise,safety (keeping the public safe from accidents and when using them to assess what people do, theyincidents), others looks primarily at Occupational will collect data about what people believe orHealth and Safety (keeping workers safe), while perceive that they do and not what they actuallyothers look at both. This is why it is so important do. On the other hand, audits and observationsfor an organisation to determine how it wants to are tools that when applied properly will more Figure 5 Possible Measurement Tools
  10. 10. Reprinted July 2012accurately reflect what is happening in the 3.4_Evaluating the Measuresworkplace as well as what the organisation has. Interpreting the results produced by theWhen determining which tools to use, there are a various safety culture measurement tools cannumber of factors that must be considered. be daunting. Each tool can have its own unique First and foremost, you must determine challenges.what it is that you are planning on measuring. It For surveys, did the respondentsis important for those planning to measure safety understand the question? Why did they answerculture to take into consideration the level of the way they did? For interviews, were thetrust of employees towards those managing the participants open and honest? If they do not trustassessment. For example if interviews or focus the process or those conducting the interviews,groups are held and there is a low level of trust, the data collected may be incomplete andthen the results may be biased. Or for a survey, if inaccurate. For audits, are you actually capturingemployees do not believe that confidentiality will the day-to-day activities or are those beingbe maintained, then the response rate may be low. audited on their best behaviour? Or perhaps they With regards to the utility of results you spent the week prior to the audit, catching up onneed to consider the amount of data that will be things.produced, how difficult it will be to analyse the By using different measurement tools, youdata and, in turn, to interpret the results. Will the can address weaknesses in one by the strengthstool allow comparability between assessments in another. For example, you can follow-up aas well as across groups? Will a link be seen safety culture survey with focus groups in orderbetween the data collection efforts and the to explore respondents’ understanding of keyidentified actions? For example, Interviews questions and to obtain a better and deepercan limit comparability particularly between understanding of the findings.assessments. Surveys can offer comparability There are many different ways to measure,between assessments as well as groups. and in turn present, the results of a safety culture Cost is important and is affected by a assessment. It is important to understand what itnumber of factors. Is there an inexpensive tool is you are measuring and what are the best meansavailable that you can purchase, can one be easily for presenting the results. Examples includemodified or do you have to undertake expensive frequency charts, radar plots and comparison’sdevelopment? How much time will be spent in against normed databases.applying the tool and analysing the results? What are the logistical costs – 3.5_Improving the Safety Culturecommunications, survey administration and travel The final step of the safety cultureare just some that need to be considered. enhancement process is “closing the safety loop”. Lastly but just as importantly you need to It is important that assessments of safety cultureconsider what is the timeframe for completion of be followed by change where weaknesses havethe activity and how quickly does the assessment been identified. Employees will disengage fromneed to be completed? the enhancement process if they see no real benefits from participating. By using the appropriate tools and accurately evaluating the results, you will be able
  11. 11. Safety Culture Definition 10_11and Enhancement Process 4 Conclusionto develop enhancement strategies and formulate The achievement of an effective safetyaction plans. Enhancement strategies will focus on culture is recognised to be a vital element ofweaknesses identified by your safety indicators. achieving and maintaining satisfactory levels ofDo you have weaknesses in the area of trust, safety performance. A Systematic Safety Culturecommunications, learning or perhaps perceptions Enhancement Process is a managerial toolon consistency between words and actions? allowing organisations to identify areas where Action plans must be realistic and safety culture may be enhanced. The process ofemployees must be able to see the links between enhancement begins with a model of an effectivethe action plans and the identified weaknesses safety culture – in other words a safety culturein safety culture. Don’t forget to consider your definition and its elements as presented previouslyorganisation’s vision or mission. Make sure that in Section 2.the actions tie into the business plan if you hope The enhancement process moves ontoto have senior management support and the measuring and evaluating the safety culture.necessary resources to undertake the planned There are many available tools for measuring andactions. Here is where you look back to those evaluating safety culture. The selection of thesafety culture drivers. Look to see how you can appropriate measurement tools begins with thebest use them to drive your action plans. model and takes many factors into effect including Finally remember that timely feed-back and but not limited to cost, time, confidentialityfollow-up is critical - do this as soon as possible requirements, ease of data analysis and usefulnessafter completion of the assessment so that staff of output for planning of enhancement actions. Thesees that momentum is being maintained. If your CSCWG will begin to look at developing such toolsare providing feedback following the introduction in future years.of enhancement actions or other changes, make It is important to recognise that theclear how the changes relate to the findings of the Systematic Safety Culture Enhancement Processsafety culture assessment, what the changes are is a closed loop system. Following implementationand what employees can expect to see. Do this at of enhancement actions, an organisation mustthe beginning of the feedback process. begin again by measuring the safety culture to determine the impact of those actions. Did they have the intended effect? Are there areas that require further enhancement or fine tuning? As Mao Tse Tung once said, “Peoples attitudes and opinions have been formed over the decades of life and cannot be changed by having a few meetings or giving a few lectures”. And finally, a last thought from James Reason: If you are convinced that your organisation has a good safety culture, you are almost certainly mistaken ... a safety culture is something that is striven for but rarely attained. The virtue – and the reward – lies in the struggle rather than the outcome.
  12. 12. CANSO Members CANSO – The Civil Air Navigation Services Organisation – is the global voice of the companies that provide air traffic control, and represents the interests of Air Navigation Services Providers worldwide. CANSO members are responsible for supporting over 85% of world air traffic, and through our Workgroups, members share information and develop new policies, with the ultimate aim of improving air navigation services on the ground and in the air. CANSO also represents its members’ views in major regulatory and industry forums, including at ICAO, where we have official Observer status. For more information on joining CANSO, visit Lighter areas represent airspace covered by CANSO MembersFull Members - 74— Aeronautical Radio of Thailand (AEROTHAI) — Maldives Airports Company Limited (MACL) — ATCA – Japan— Aeroportos de Moçambique — Malta Air Traffic Services (MATS) — ATECH Negócios em Tecnologia S/A— Air Navigation and Weather Services, — NATA Albania — Aviation Advocacy Sarl CAA (ANWS) — National Airports Corporation Ltd. — Avibit Data Processing GmbH— Air Navigation Services of the Czech Republic — National Air Navigation Services Company — Avitech AG — AZIMUT JSC (ANS Czech Republic) (NANSC) — Barco Orthogon GmbH— Air Traffic & Navigation Services (ATNS) — NATS UK — Booz Allen Hamilton, Inc.— Airports and Aviation Services Limited (AASL) — NAV CANADA — Brüel & Kjaer EMS— Airports Authority of India (AAI) — NAV Portugal — Comsoft GmbH— Airservices Australia — Naviair — Abu Dhabi Department of Transport— Airways New Zealand — Nigerian Airspace Management Agency (NAMA) — Dubai Airports— Angkasa Pura I — Office de l’Aviation Civile et des Aeroports — EADS Cassidian— Austro Control (OACA) — EIZO Technologies GmbH— Avinor AS — ORO NAVIGACIJA, Lithuania — European Satellite Services Provider (ESSP— AZANS Azerbaijan — PNG Air Services Limited (PNGASL) SAS) — Emirates— Belgocontrol — Polish Air Navigation Services Agency (PANSA) — Entry Point North— Bulgarian Air Traffic Services Authority — Prishtina International Airport JSC — Era Corporation (BULATSA) — PT Angkasa Pura II (Persero) — Etihad Airways— CAA Uganda — ROMATSA — Fokker Services B.V.— Civil Aviation Authority of Bangladesh (CAAB) — Sakaeronavigatsia Ltd — GE Aviation’s PBN Services— Civil Aviation Authority of Singapore (CAAS) — S.E. MoldATSA — Guntermann & Drunck GmbH— Civil Aviation Regulatory Commission (CARC) — SENEAM — Harris Corporation— Department of Airspace Control (DECEA) — Serbia and Montenegro Air Traffic Services — Helios— Department of Civil Aviation, Republic of Agency (SMATSA) — HITT Traffic Cyprus — Serco — Honeywell International Inc. / Aerospace — IDS – Ingegneria Dei Sistemi S.p.A.— DFS Deutsche Flugsicherung GmbH (DFS) — skyguide — Indra Navia AS— Dirección General de Control de Tránsito — Slovenia Control — Indra Sistemas Aéreo (DGCTA) — State Airports Authority & ANSP (DHMI) — INECO— DSNA France — State ATM Corporation — Inmarsat Global Limited— Dutch Caribbean Air Navigation Service — Tanzania Civil Aviation Authority — Integra A/S Provider (DC-ANSP) — The LFV Group — Intelcan Technosystems Inc.— ENANA-EP ANGOLA — Ukrainian Air Traffic Service Enterprise — International Aeronavigation Systems (IANS)— ENAV S.p.A: Società Nazionale per l’Assistenza al (UkSATSE) — Iridium Communications Inc. Volo — U.S. DoD Policy Board on Federal Aviation — Jeppesen— Entidad Pública Aeropuertos Españoles y — LAIC Aktiengesellschaft — LEMZ R&P Corporation Navegación Aérea (Aena) Gold Associate Members - 13 — LFV Aviation Consulting AB— Estonian Air Navigation Services (EANS) — Abu Dhabi Airports Company — Micro Nav Ltd— Federal Aviation Administration (FAA) — Airbus ProSky — The MITRE Corporation – CAASD— Finavia Corporation — Boeing — MovingDot— GCAA United Arab Emirates — BT Plc — New Mexico State University Physical Science Lab— General Authority of Civil Aviation (GACA) — FREQUENTIS AG — NLR— Hellenic Civil Aviation Authority (HCAA) — GroupEAD Europe S.L. — Northrop Grumman— HungaroControl Pte. Ltd. Co. — ITT Exelis — NTT Data Corporation— Israel Airports Authority (IAA) — Project Boost — Lockheed Martin— Irish Aviation Authority (IAA) — Quintiq — Metron Aviation— ISAVIA Ltd — Rockwell Collins, Inc. — Raytheon — Rohde & Schwarz GmbH & Co. KG— Kazaeronavigatsia — SELEX Sistemi Integrati S.p.A. — Saab AB— Kenya Civil Aviation Authority (KCAA) — Telephonics Corporation, ESD — Saab Sensis Corporation— Latvijas Gaisa Satiksme (LGS) — Thales — Saudi Arabian Airlines— Letové prevádzkové Služby Slovenskej — SENASA Republiky, Štátny Podnik Silver Associate Members - 61 — SITA— Luchtverkeersleiding Nederland (LVNL) — Adacel Inc. — STR-SpeechTech Ltd.— Luxembourg ANA — ARINC — Tetra Tech AMT — Washington Consulting Group — WIDE Correct as of 5 July 2012. For the most up-to-date list and organisation profiles go to