Synthesizes the latest findings in neuroscience and psychology with real life lessons from cultural transformation efforts in a variety of settings from large, multi-national corporations to small helicopter operators. References for this work include Daniel Kahneman’s Thinking Fast and Slow; Dr. Richard Restak’s The Naked Brain and Mozart’s Brain and the Fighter Pilot; Daniel Goleman’s Focus; Everett Rogers’ Diffusion of Innovations, Charles Duhigg’s The Power of Habit; and the NTSB report NTSB/AAB-06/06, PB2007-100699 on the crash of a Gulfstream III on approach to Houston’s Hobby Airport on 22 November 2004.

1. Breaking the Barriers to a Generative Culture
CHC Safety & Quality Summit
Vancouver – 2014

2. Culture – the final frontier.

3. Why a Generative Culture?
• Typical human:
– Resists change
– Seeks cognitive ease
– Acts out of habit 95% of the time
• Habits create culture.
• People tend to act out of cultural norms.
• A generative culture can deliver habit-strength
safe behaviors.
Basal Ganglia

4. The Whole System for Safety
• Goal
• Strategy
• Structure
• Culture

5. International Helicopter Safety Team
• Initial goal set in 2006: reduce the global
accident rate by 80% within the next 10 years
• Current vision: an international civil
helicopter community with zero accidents

7. OGP Safety Commitment (2004)
“The individual risk per period of flying exposure
for an individual flying on OGP contracted
business should be no greater than on the
average global airline.”

8. Completing the Mission Safely
• Goal
• Strategy
• Structure
• Culture

9. • New helicopters
• Training
• Quality and safety management systems
• Health & Usage Monitoring Systems (HUMS)
• Flight Data Monitoring (FDM)
• Disciplined take-off and landing profiles
• Avionics to prevent CFIT and mid-air
collisions (EGPWS/TAWS & TCAS/ACAS)
OGP Air Safety Strategy

10. IHST Focus Areas
• Safety Management Systems (SMS)
• Training
• Systems & equipment
Health monitoring systems (HUMS)
Flight data monitoring (FDM) systems
• Maintenance

11. Completing the Mission Safely
• Goal
• Strategy
• Structure
• Culture

12. Support Structure
• Proactive Hazard Identification & Management
• Supporting Policies, Procedures, Measures and Controls
• Pre-flight risk assessment
• Operating controls
• Competent resources – effectively organized
• People
• Equipment
• Open reporting in a Just Culture
• Root cause investigation and corrective actions
• Safety promotion and information sharing in a Learning Culture
• Audits and reviews for continuous improvement

13. SCOPE OF ACTIVITY
IDENTIFY AND RECORD
HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR
SPECIFIC HAZARDS
REFERENCE DOCUMENTS
AND RESPONSIBLE POSTS
REMEDIAL
ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL
DEVELOPED
QUALITY SYSTEM
– UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
SAFETY REPORTING
& INVESTIGATION
PROCESS NEW HAZARDS
MANAGEMENT
OF CHANGE
PROCESS
MANAGEMENT
REVIEW
VALIDATE EXISTING CONTROLS
OR DEVELOP NEW CONTROLS

14. Detailed RAM
once

15. Safety Bowtie
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16. Support Structure
• Proactive Hazard Identification & Management
• Supporting Policies, Procedures, Measures and Controls
• Competent resources – effectively organized
• Open reporting in a Just Culture
• Root cause investigation and corrective actions
• Safety promotion and information sharing in a Learning Culture
• Audits and reviews for continuous
improvement

17. Audits & Review

18. Results?

19. 0
2
4
6
8
10
12
14
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
FatalAccidentsperMillionFlyingHours
Oil & Gas Industry
Fatal Helicopter Accident Rates
Oil Industry FARex-OGP ASC Oil Industry FAR OGP ASC FAR
FatalAccident Rate(FAR)permillionflying hours -five-year rollingaverage
Therearestatisticallysignificantdifferencesbetweentheindustry
andtheOGP AviationSubCommittee(ASC)trends.
Total Oil -/Gas Industry
Rest of Oil -/Gas Industry
Aviation Subcommittee
Members
Source:InternationalAssociationof Oil & GasProducersAviationSubcommittee

20. 0
100
200
300
400
500
600
700
800
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Global Civil Helicopter Accidents
Pre-IHST Accidents Baseline Average Post-IHST Accidents
Milestones Pre-IHST Trend Post-IHST Trend
Average of 587 accidents per year
from 2001 thru 2005

22. “Culture is set by the
guy who pays the
bills.”
Lee Benson, Former Chief Pilot for the
Air Operations Section of the Los
Angeles County Fire Department
Peter Drucker
“Culture eats
strategy for
breakfast.”

23. Culture
Culture: The Mother of all Root Causes

24. The Safety Culture Ladder
Reference: Hearts & Minds - http://www.eimicrosites.org/heartsandminds/

25. Generative Culture
• Mindfulness
– Alert caution
– Compliance
• Learning
– Reporting
– Just Culture
• Continuous improvement
– Sharing internal & external information
– Collaboration
#1 Question:
Can people talk
about their
concerns?

26. Cultural Changes

27. The Tipping Point
CRITICAL MASS
Communication channels must provide:
knowledge,
persuasion,
decision,
implementation,
and confirmation
Reference: Everett Rogers

28. Requirements for Change
• Relative Advantage
• Compatibility
• Simplicity
• Trial ability
• Observability
Reference: Dr. Everett M. Rogers, Diffusion of Innovations

29. Changing Habits

30. At the Root
Beliefs
Behaviors
Habits
Culture“Great leaders talk about
their beliefs and attract
people who believe what
they believe.”
- Simon Sinek
Do people in your
workplace talk about their
beliefs about safety?
“People don’t
resist change,
they resist being
changed.”

31. Ego
From An Invitation to Enter the Now by Sami Cohen

32. Role Play Scenario
Captain
• 19,000 total hours
• ATPL
• Multiple Type Ratings
• Chief Pilot until 31 July
First Officer
• 19,100 total hours
• ATPL
• Multiple Type Ratings
• Chief Pilot after 31 July
Weather
100’ broken with 1,600 feet RVR
Mission
En route to pick up a Very, Very Important Person

33. Questions
• Cues?
• Routines?
• Rewards?
• Desires or beliefs supporting the routines?
• The role of the egos?
Feel free to speculate!

34. ILS Approach to Runway 4

35. CVR & Flight Path
Time Comments State of Flight
05:58:50 Houston Terminal Radar Approach
Control (TRACON) cleared the
flight directly to CARCO, adding,
“when you’re able for the ILS
runway four.”
18,000 feet headed
southeast
06:05:05 TRACON instructed “descend to
and maintain 3,000 feet”
11,000 feet headed
southeast
06:10:43 TRACON instructed the flight crew
to turn left heading 070° and to
maintain an altitude of “2,000 feet
or above ‘til established
[on the] localizer.”
Descending on a
southeasterly
heading

36. CVR & Flight Path
Time Comments State of Flight
06:11:13 The First Officer stated “localizer’s
alive.”
Descending through
2,900 feet and
turning left
06:11:57 First Officer contacted the HOU air
traffic control tower (ATCT) and
stated “with you on the ILS.”
Descending through
2,300 feet and
turning left
06:12:15 Captain told First Officer “I can’t
get approach mode on my thing.”
Descending and
turning left
06:12:57 First Officer says “what [is] wrong
with this?” Captain replies “I don’t
know.”
Descending and
turning left, 600 to
1,000 feet below the
glideslope
Cues?
Routines?
Rewards?
Beliefs?
Egos?

37. Stress

38. CVR & Flight Path
Time Comments State of Flight
06:13:03 First Officer says “what do we have
set wrong? We have…long range
[navigation or NAV] or something…
that we shouldn’t have?”
Descending and
turning left, 600 to
1,000 feet below the
glideslope
06:13:08 The Captain reported, “got
NAV…VOR one.”
Descending and
turning left, 600 to
1,000 feet below the
glideslope
06:13:10 The First Officer stated, “okay,
we’re high on the glideslope now,”
and the Captain replied, “just
gonna have to do it this way.”
Descending and
turning left, 600 to
1,000 feet below the
glideslope
Cues?
Routines?
Rewards?
Beliefs?
Egos?

39. Avionics

40. CVR & Flight Path
Time Comments State of Flight
06:14:05 The Captain asked “what
happened? did you change my
frequency?” The first officer
responded, “yeah we were down
there…the VOR frequency was on.”
He then stated, “we’re all squared
away now…you got it.” The captain
responded, “yeah, but I, I don’t
know if I can get back on it in
time.” The first officer replied,
“yeah you will…you’re squared
away now.”
Intercepting localizer
course and
descending through
900 feet, 800 feet
below the glideslope
06:14:45 First Officer “Up, up, up, up, up,
up, up”
06:14:47 Impact with a light
pole.
Cues?
Routines?
Rewards?
Beliefs?
Egos?

41. Lessons?
• One thing?
• One more thing?

42. Training for
Habit-Strength Safe Behaviors
Routine
Cue RewardBeliefs & Desires
Recognition Immediate
Positive
Certain
Deep Understanding
Substitution

43. Focus
1) Biggest risks
2) Good & bad routines
3) Good & bad cues
4) Rewards
5) Shared beliefs
Train to habit strength on
• Motor skills
• Technology
• Mindset
Leverage “keystone habits”
Routine
Cue RewardShared Beliefs

44. Focus
Correlation between numbers:
Big Change Efforts  Big Change Successes
• 3  3
• 5  < 5
• > 5  < 3
• > 10  0
• One thing at a time

45. Safety Bowtie
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Cues?
Cues?
Routines
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Routines

46. Leverage
What is the one thing you can do
such that by doing it everything else
will be easier or unnecessary?
Reference: The One Thing by Gary Keller

47. Zero Accidents
• Goal or Vision
• Strategy
• Structure
• Culture

48. References
• Energy Institute, Hearts and Minds,
http://www.eimicrosites.org/heartsa
ndminds/
• Professor Patrick Hudson
• Simon Sinek, Why and
http://www.ted.com/talks/simon_sin
ek_how_great_leaders_inspire_actio
n.html
• Daniel Kahneman, Thinking, Fast and
Slow
• Daniel Goleman, Focus
• Charles Duhigg, The Power of Habit
• Dr. Richard Restak, The Naked Brain
and Mozart’s Brain and the Fighter
Pilot
• Dr. Everett Rogers, The Diffusion of
Innovations
• Sami Cohen, An Invitation to Enter
the Now
• NASA report on GIII Crash on
Approach to Houston Hobby on 22
November
2004,http://www.ntsb.gov/doclib/re
ports/2006/aab0606.pdf
• Bob Williams, Aviation Advisor, Field
Support Services, ExxonMobil
Aviation Services (OGP data)
• International Helicopter Safety Team
(www.ihst.org)
• Gary Keller, The One Thing

49. Summary
• Helicopters save lives and do vital work, but the
global helicopter accident rate is still
unacceptable.
• Culture dominates!
• You can change the culture:
– Discuss beliefs and share the vision of zero accidents
– Train for habit-strength safe behaviors
– Find and leverage the “keystone habits”
– Make it safe to express concerns
– Spread the word

50. Breaking the Barriers to a Generative Culture
CHC’s Safety & Quality Summit
Vancouver – 2014
Questions?
Thank you!