Here are the key behaviors identified to support safety: - Open communication - Willingness to report issues/concerns - Awareness of hazards - Adherence to procedures - Continuous learning - Accountability - Teamwork - Leadership commitment to safety

1. Safety Culture
Development in 5 Star
Airlines
“It’s how we behave when there is no-one else around”
180814 0255

2. Welcome - House keeping

3. Introductions

4. Our Agenda
• Defining a just safety culture & psychology
• Challenges to implementing a safety culture
• Key skills supporting safety
• Fear and the Power Distance Index
• Implementation
• Innovation & change
• Selling a Just Safety Culture.

5. My Assumptions
• you are all a part of SAG 1, 2 or 3
• you have been participating in a ‘Blue Ocean’ sessions
seeking innovative ways to increase safety
• My focus will be on what some Airlines and other
organisations at the top of their field are doing to create a
S Safety Culture
• This is also an opportunity to refresh your safety knowledge.

6. Facts
• Deaths involving commercial aircraft in flight are reducing,
with no deaths recorded in 2017.
• At the same time, there were over 2.78 million deaths in
the workplace (non flight), higher than the 2.33 million
deaths in 2014.
• Asia was the highest contributor and constituted about
two-thirds of the global work related mortality, followed by
Africa at 11.8% and Europe at 11.7%.
Source: Workplace Health and Safety Singapore

7. What if your workplace is totally safe…what
would it be like?
Take 5 minutes in your teams to discuss

8. Defining a Safety Culture
Why do we want this for Vietnam Airlines?
“Safety culture is defined as the way in which safety is
managed in the workplace. It is the combination
of beliefs, attitudes and behaviors of people toward the
safety of workers and the over safety off the work environment”.
“It is the way in which we behave when nobody else is around”.

9. Common Challenges to Safety as a
Culture
• Assigning blame rather than identifying the problem
• Negative re-enforcement
• Making it about the employee only, and not the environment
• Poor safety targets - low injury rates or days without
incident usually leads to reduced reporting and non
reporting of near misses
• Looking at the outcome only and not the journey. EBT is a
good example
• Incorporating safety at every level - from the top down.

10. Defining a ‘Just’ Safety Culture
“A Just Safety Culture is a culture where they are not punished
for their actions, omissions or decisions taken by them which
are commensurate with their experience and training, but where
willful violations and destructive acts are not tolerated”.
It thrives on factual and timely reporting, investigating and the
implementation of actions to address reoccurrence.
www.eurocontrol.int/articles/just-culture

11. • Guess what….we will all make mistakes! But then what?
• We often feel we need to take risks to achieve our
objectives - OTP, workload, tiredness etc.
• Those same qualities that help us to succeed - are often
those same qualities that encourage us to take risk.
• We have a will to survive - and will often do what it
takes. Fear causes us to respond in a certain way.
• We respond better to encouragement than excessive
punishment.
‘Just’ Understanding of People

12. • Encourage people to
report incidents and near
misses quickly.
• Encourage learning from
events, not blaming.
• People are held
accountable, but punitive
punishment is not the first
response.
• Treats us as humans with
human characteristics.
• Generate trust!
So where does a ‘Just Culture’ vary from
many existing cultures?
• Encourage people to hide
incidents through fear of
retribution.
• Encourage a blame
culture based on basic
human survival.
• First response - who is to
blame and what is the
damage/punishment?
• Thinks we are system
driven machines.
• Encourages mistrust!
Just Cultures ‘Other’ Cultures

13. Must be simple and also be responded to
Reporting
Experience has shown us that
Confidentiality is a must, but so
is providing your name!

14. Just Culture encourages forward looking
accountability
Continually asking the questions:
• Who (else) could be hurt - what happened or
might have happened?
• What do we need to do now - my immediate
action?
• Whose obligation is that - who do I need to
inform?
sidneydekker.com

15. Does a Just Culture mean we do not
hold people accountable?
Your answer?
NO!
Just Culture is not excessively punitive, nor is it liberal.
Negligence
Conscious
disregard of
unjustified risk
At-risk behavior
Choice that
increases risk
Honest mistake
Unintended,
inadvertent lapse,
slip
sidneydekker.com

16. Retribution versus Restorative Approach
• What rules were
broken?
• How bad was the
mistake?
• What are the
consequences?
• What are we
learning?
• What can we do to
stop this happening
again?
• What do we do
now?
Retribution - Looks back Restorative - Looks forward
sidneydekker.com

17. Protection and Review
Just Safety Culture requires a level of protection for
those involved
• Decision makers and investigators are to be independent
• Both groups must have knowledge of the involved
processes, environment, duties etc
• There must be a ‘right of appeal’.
sidneydekker.com Why are these three points important?

18. What is at stake
• For airlines to be safe and a place of safety, openness and trust,
we must embrace ‘just’
• ‘Just’ is defined as ‘based on or behaving according to what is
morally right and fair’ [Oxford Dictonary]
• The EU has already passed laws around via regulations (EU) No.
691/2010 and 996/2010 enacting Just Safety. Others are
following.
• ICAO, IATA and other prominent organizations support Just-
ness.

19. Human Behavior - Isn’t a Just Safety
Culture Logical?
Discuss in your teams how humans respond to the various
aspects of safety and why we struggle with our behavior towards
safety?

20. Human Behavior - Growth
The Psychology of Coaching
1- Unconsciously
Not Competent
‘you don’t know whatyou
don’tknow’
4- Unconsciously
Competent
‘You do the right thing without
consciously thinking’
2 - Consciously
Not Yet Competent
‘You know the rightway,
but don’talways do it’
3- Consciously
Competent
‘You know whatto do,
consciously think aboutit
and then do it’
AwarenessRaising
Competency Development
Experience
Copyright© 2009 ETM Australia

21. Activity: In your four teams:
how do you describe people in your box (1-4) and how do
we manage their growth and level of safety competence?
The Psychology of Coaching
1- Unconsciously
Not Competent
‘you don’t know whatyou
don’tknow’
4- Unconsciously
Competent
‘You do the right thing without
consciously thinking’
2 - Consciously
Not Yet Competent
‘You know the rightway,
but don’talways do it’
3- Consciously
Competent
‘You know whatto do,
consciously think aboutit
and then do it’
AwarenessRaising
Competency Development
Experience
Copyright© 2009 ETM Australia

22. Human Behavior - We find comfort in
habits
V
V
What we see
Drives our behavior
Repetition of behavior

23. What contributes to FEAR as -
the safety killer

24. Power and its impact on our ability to
act - The Power Distance Index
• hello
www.hofstede-insights.com

25. Case Study One
While disembarking from a flight at Dubai airport in 2014, a passenger noticed an odd
object protruding from the flaps area on an A330. The passenger reported his
observation to a cabin crew member who dismissed the passengers claim as
impossible. This then upset the passenger who went and found another cabin crew
member, however, the response of disbelief and dismissal was similar to the first cabin
crew member. Finally, the passenger approached a senior member of the crew who
accompanied the passenger back to their window and confirmed that something was
indeed amiss.

26. Case Study One
While disembarking from a flight at Dubai airport in 2014, a passenger noticed an odd
object protruding from the flaps area on an A330. The passenger reported his
observation to a cabin crew member who dismissed the passengers claim as
impossible. This then upset the passenger who went and found another cabin crew
member, however, the response of disbelief and dismissal was similar to the first cabin
crew member. Finally, the passenger approached a senior member of the crew who
accompanied the passenger back to their window and confirmed that something was
indeed amiss.
30 minutes later an engineer removed a wrench from the flaps area. It was was a miracle
that the wrench did not interfere with the operation of the flaps, or that it had not
dislodged in flight and caused damage to the aircraft, became FLOT on the runway, or
fallen from the aircraft in flight and potentially killed someone on the ground.

27. Case Study One
While disembarking from a flight at Dubai airport in 2014, a passenger noticed an odd
object protruding from the flaps area on an A330. The passenger reported his
observation to a cabin crew member who dismissed the passengers claim as
impossible. This then upset the passenger who went and found another cabin crew
member, however, the response of disbelief and dismissal was similar to the first cabin
crew member. Finally, the passenger approached a senior member of the crew who
accompanied the passenger back to their window and confirmed that something was
indeed amiss.
30 minutes later an engineer removed a wrench from the flaps area. It was was a miracle
that the wrench did not interfere with the operation of the flaps, or that it had not
dislodged in flight and caused damage to the aircraft, became FOD on the runway, or
fallen from the aircraft in flight and potentially killed someone on the ground.
A subsequent investigation revealed that several systems and protective measures had
all failed leading up to event.
It was an almost perfect example of Reason’s Swiss Cheese Model
In your groups, what are some of the issues/concerns you see with this event

28. AAP Gateway

29. Key Skills supporting Safety
Activity:
In your four teams:
In your opinion, what are five (or more) key
behaviors needed to support safety?

30. Characteristics of a healthy safety culture
• Management commitment - Safety reps at every level
• Good housekeeping
• Multi-faceted communications
• Healthy reporting of ‘near misses’
• Hazard recognition
• Well trained and educated staff
• Quality orientation programs (multi-level)
• Use of related technology

31. Clarify Safety
Responsibilities
Review
Investigation and all
procedures
Communicate,
communicate,
communicate
Provide Training
Reporting
Learn & Take Action
Make it a daily event
Involve Everyone
Lead by example
Share and live the safety vision
All policies and procedures are ‘just’ and not ‘blame’ based
Ensure accountability starting with
managers and supervisors
Prepare for increased demand
Be ‘solution’ based and not ‘blame’ based
Good &
Bad issues
Shared responsibility
Orientation plus ongoing safety training
At every level of the organization
Image: Grunau Company
A just methodology

32. This all seems totally logical?
In your groups, How do we know if a Just Safety
Culture is working?

33. Case Study Two
We can all agree that you can’t simply direct an airline to implement a Just Safety
Culture and expect it to happen.
• A Just Safety Plan is required - with sponsorship from the highest level.
• Related policies and procedure need to be reviewed
• Public statements need to be made
• Just Safety content needs to be added to every training course and
management meeting agendas
• A change strategy is required to move the organization from current to
expected
• Training packages need to be developed, delivered and evaluated
• Quality control and measures established.
What will be your great challenges with this list?

34. Innovation and where it fits
• Your are well placed to innovate - challenge your habits!
• It is ongoing…..if it works, how can we do it better
• What human characteristics support innovation?
• All innovation leads to change!

35. Activity: Innovative Safety Initiatives
In your four teams:
What innovative ideas do you have on how we
can enhance our safety culture?

36. Innovation Example 1 - Safety App
Level 1
Training
Centre
Level 2
Combines
questions and
regulations to
reach
Level 3
The Psychology of Coaching
1- Unconsciously
Not Competent
‘you don’t know whatyou
don’tknow’
4- Unconsciously
Competent
‘You do the right thing without
consciously thinking’
2 - Consciously
Not Yet Competent
‘You know the rightway,
but don’talways do it’
3- Consciously
Competent
‘You know whatto do,
consciously think aboutit
and then do it’
AwarenessRaising
Competency Development
Experience
Copyright© 2009 ETM Australia

37. A Safety App….
Educates
Updates
Regulates
…while allowing us to see
safety in action

38. How to sell a Just Culture
In your groups:
1. Who are the stakeholders and what are their needs?
2. What are the selling points of a Just Safety Culture

39. Primary challenges to implementing a
Just Safety Culture
• Lack of resources to support safety
• Insufficient buy in by leadership at most levels
• Don’t collect or ignore feedback
• Lack of education/understanding
• An ….’its just another fad’….attitude.

40. Just Safety Culture Check List
1. Robust communication channels, both vertical and horizontal
2. Management commitment, leadership buy in
3. Collection and publicizing of near miss reporting
4. Good housekeeping culture and hazard identification
5. Stable workforce with low staff turnover
6. Good system of talent identification and promotions
7. Well trained workforce who know their safety procedures
8. Extensive Orientation program for all people new to role or
organization (includes contractors).
In your teams - score your organization between 1-10 for each

41. Change Management 101
Activity: In your four teams:
1. What changes need to occur in your organization to change to a
‘just safety culture’?
2. What changes can you start to make immediately yourself?
3. How can you manage the change process for both 1 & 2 above?

42. Change Management 101
Step 1 - Determine the need for change - it may be your own initiative, or it may be
imposed.
Step 2 - Consider and develop the change idea further in your own context -
especially if the change is imposed from higher. Consider any additional detail you
need to plan for to effectively implement the change.
Step 3 - Float the idea to include others and to assess areas of concern - lobby
your management team or your own team (if appropriate) to hear their concerns,
identify risks, issues etc.

43. Change Management 101
Step 4 - Detailed planning. Who, What, Why, When, Where and How.
Step 5 - Announce the change. Sell it! Whether you believe in the change can be
immaterial.
Step 6 - Grieving time. Grieving time is a length of time between when the change is
officially announced and when the change is executed. This time gives people a period
of time to mentally adjust to the change so that they can think about and get used to
the idea.
Step 7 - Execute. Do it with enthusiasm and energy, even if the change is widely
perceived as a ‘negative event’.

44. Change Management 101
Step 8 - Monitor. Watch the plan and watch your people. Ensure that the change is
being applied and ensure you measure the results.
Step 9 - Evaluate. This should be both informal and formal. Start with informal to meet
with stakeholders to gain their opinions on the change. Don’t judge - just listen with an
open mind as these people have been living through the change and will provide you
with their valuable insights which may be to your benefit.
Step 10 - Report the results. Report the results to all stakeholders. It is important to
highlight background of the change, what was achieved, and what has been learned.
Step 11 - Officially close the change project. Announce its completion in conjunction
with Step 10.
Step 12 - Celebrate with the team!
Note: Critical steps often missed are Steps 6 and 9.

45. Action Planning

46. “what can you do to
create a new and
more ‘Just’ culture”?
Image: Angus Munro Psychology

49. From this on are additional reference materials and resources