Improving Safety Culture in Air Traffic Control
From SKYbrary Wiki
- 1 Background
- 2 Objective
- 3 Planning and Managing the Change
- 3.1 Effectiveness / Feasibility evaluation
- 3.2 Senior Management Commitment
- 3.3 Establishing Blame and Reward Policy - Just Culture
- 3.4 Communicating for Safety
- 3.5 Improving Organisation’s SMS through Safety Culture Principles
- 3.6 Empowering Employees to Participate in the Safety Culture Improvement Process
- 3.7 Building Trust
- 4 Safety Culture Enablers
- 5 Related Articles
- 6 Further Reading
As with any project, Safety Culture enhancement activities need to be properly planned, resourced and monitored to ensure that they achieve the intended objectives. The Safety Culture assessment process will suggest many opportunities for improvement. An additional process is required to establish the priority areas for action, and to consider limitations in what can be achieved in practice.
The Air Navigation Service Provider’s goal should be to identify:
- The most important Safety Culture improvements required (effectiveness or benefit), based on their interpretation of the diagnosis, and
- How easy will it be to make meaningful change, that is, which of the improvements will be easy to achieve and which will be more difficult (their feasibility).
Planning and Managing the Change
The first process for making these distinctions is referred to as an Effectiveness / Feasibility evaluation.
This can be undertaken via management meetings, or as a workshop activity, run by a facilitator who understands the process, and with participation from a range of stakeholders in the Safety Culture improvement project.
Effectiveness / Feasibility evaluation
Step 1: Determine the likely effectiveness of the change, through discussion of the following questions:
- What is the expected effect / benefit on safety management?
- What would be the extent (e.g., whole ANSP versus local) and depth of the effect? How durable or lasting would the effects be - long-term or temporary?
- Is there any ‘downside’, that is, potential risk or adverse colateral effect from the change (e.g., risk transfer or creation of new risks)?
Step 2: How feasible is the action, in terms of factors such as cost, practicality and difficulty:
- What is the financial cost?
- What operating constraints or limitations apply? How will the target population be affected by and respond to the intervention?
- How complex and widespread will the impact be on the organisation as a whole, on policies, procedures and practices; on structures; on regulatory compliance; and on socio-political systems (powers, status, corporate interests).
Key steps in planning and managing cultural change are:
- Establish commitment to the project
- Clearly define the scope, objectives and timeframe
- Identify and allocate funding
- Agree in advance the measures of success
- Prepare a project plan (summarising issues above)
- Identify risks, and ways to manage these
- Assign responsibilities for activities to the Project Team
- Set up monitoring processes (for resources, objectives, output and timeliness)
- Report progress and communicate achievements
- Celebrate success!
It should be remembered also that cultural change projects are somewhat intangible, in that the desired changes in attitudes may be hard to see, and the behavioural effects may be gradual and subtle. This means momentum for the project may fall away unless commitment and project controls are actively maintained, and the project is given ongoing prominence in the organisation - through regular reporting and communication of progress.
Senior Management Commitment
A commitment to safety by the organisation’s senior management group is essential to the existence of a positive Safety Culture. The simplest way for managers to show commitment is through their behaviour - the things they say and do.
Two preliminary steps are important:
- First, become informed about the organisation and its risks; about the nature of Safety Culture; and about the impact of (collective) decisions and actions on safety. This information can come from the formal culture assessment activities, research, and informal information gathering.
- Second, develop integrated strategy and supporting plans for safety improvement that recognise the importance of Safety Culture and guarantee the necessary level of resourcing, regardless of financial pressures.
To begin changing behaviour, identify exactly what it is that distinguishes managers who are highly committed to safety from those who are not interested in, or only pay ‘lip-service’ to safety. These ‘management safety competencies’ allow managers to ‘walk the talk’, for example, by:
- Promoting safety and communicating the right messages
- Leading or participating in safety meetings, workshops and forums
- Encouraging people to report hazards, safety concerns and ‘normal errors’
- Listening to, and addressing employee concerns
- Treating people justly when they report ‘normal errors’
- Being ‘visible’ in the workplace, and
- Maintaining safety standards, by example, and by correcting unsafe behaviour by others.
Establishing Blame and Reward Policy - Just Culture
Establishing blame and reward policies outlining the organisational Just Culture is not only an ethically responsible way of dealing with inevitable human errors - it is a pre-condition for reporting systems that enable an organisation to learn about the errors, hazards and risks inherent in its operations.
Communicating for Safety
Communication is a fundamental and essential process through which people cooperate to achieve any mutual goal. An effective leader would support a Safety Culture by:
- Promoting safety - as a priority, reporting related activities and highlighting achievements
- Clarifying safety goals - explaining the vision for safety, expressing clear expectations about safe behaviour
- Interacting ‘at the coalface’ - being visible, discussing safety issues
- Listening - to safety concerns, seeking feedback, asking about problems
- Closing the loop - asking how incidents occur, communicating lessons from safety occurrences, notifying improvements made
- Shaping behaviour - acknowledging and rewarding good behaviour, challenging and correcting inappropriate actions
- Being just - communicating an understanding that people are fallible and will make errors, applying a ‘Just Culture’ policy.
Feedback processes are essential to a positive Safety Culture, so that managers can understand where to make improvements to safety practices.
Upward communication channels generally exist in any organisation. These include face to face activities, such as meetings, briefings and debriefs, as well as written processes, such as event reporting systems and hazard notification forms. All of these communication channels provide the opportunity for frontline operators to pass relevant information to their supervisors or managers.
In addition, line supervisors / first level managers are supposed to observe and talk to their staff, and report to their managers.
As with many aspects of organisational functioning, there is a distinction between policy - what should happen, and practice - what actually occurs. Often, these processes of upward communication and feedback are ineffective. There are many possible reasons for this. They include what might be called ‘barriers’ to effective communication. (See Figure 1)
Improving Organisation’s SMS through Safety Culture Principles
A properly implemented Safety Management System (SMS) operates in a complementary and interdependent way with the Safety Culture to create a safer organisation. The SMS must be actively improved and realised. A Safety Management System represents an organisation’s competence in the area of safety, and it is important to have an SMS and competent safety staff to execute it.
- For additional information see: Interdependence between Safety Culture and Safety Management Systems in ATM.
Empowering Employees to Participate in the Safety Culture Improvement Process
The misperception is sometimes held that safety management should be based on formalised processes, detailed, prescriptive procedures and strict hierarchical control over work practices and decisions.
In reality, this is impossible. Even well-written, detailed procedures cannot prescribe people’s behaviour in every work situation. Neither can they be constantly supervised, to ensure that employees do the right thing. Moreover, operational goals (like productivity, timeliness and customer service) often encourage inappropriate action - for example, to cut corners or ‘bend the rules’.
It is better therefore to share responsibility for operational safety decisions. In practice this means involving ATCOs, technicians and other safety critical employees in making important decisions about the dynamic, and sometimes unpredictable, operational environment. These decisions are of course limited by clearly established guidelines and based on a known level of professional competence.
The term empowerment is often used to describe this involvement. It simply means giving employees the necessary skills, knowledge, information and authority that enable them to act with a high degree of independence in achieving specified work objectives in the most effective, safe and efficient way.
Empowerment also has significant additional benefits to safety. Employees gain a sense of independence and healthy self-importance when given responsibility. This is likely to encourage them to report problems and operational threats more readily, to represent safety concerns assertively, and to express higher expectations about their organisation’s safety management practices.
Trust can be defined as a belief or expectation that someone will do what they say they will. Because safety is dependent on cooperation between people and the open sharing of sensitive information, a positive Safety Culture cannot survive without trust.
Trust is necessary in each of the following relationships:
- Employees’ trust of their managers, created for example by managers encouraging people to speak up and report safety problems without fear of being blamed.
- Employees’ trust of their colleagues. This will be evident from a work environment that allows everyone to do their job with a reasonable level of confidence that things will go well (that not everything needs to be double checked); where stress levels are manageable; and where people display appropriate wariness about threats or hazards.
- Managers’ trust of employees. This is evident, for example, when they empower employees to make or inform local safety decisions.
Safety Culture Enablers
Educating Senior Management about Safety
All senior managers have an implicit (if not explicit) accountability for the safety performance of their organisation, yet their professional training and background rarely provides the specific knowledge and skills necessary to meet this responsibility. To carry out their safety responsibilities effectively, senior managers require specialist education in safety and human factors.
Supervisors' Safety Leadership
First level supervisors in any organisation have an important influence on safe behaviour in the workplace, executed through the variety of responsibilities or ‘sub-roles’ they perform. The competence to perform effectively in these different roles needs to be actively developed.
Team Resource Management
Team Resource Management (TRM) training can be a powerful Safety Culture improvement enabler. A properly designed, implemented and sustained TRM program is an important safety initiative for any ANSP.
Accidents and other safety occurrences are, however, only the ‘tip of the iceberg’ in regard to understanding the reliability of the ATM system. Relatively common everyday situations (e.g., problems, complexities, threats) and controller re-actions to these (errors, adaptations, improvisations etc.) can provide valuable insight into inherent weaknesses, even though no reportable event occurs.
Direct observation of controllers performing their everyday work is a recently developed technique for understanding better the nature of threats, errors and safety-related risks in the ATM system. Safety observation schemes have been developed recently to capture information about the ‘normal’ operational environment and everyday operator behaviour. An example of such a scheme in ATM is Competence assessment scheme, NATS Day-2-day observation and the Normal Operations Safety Survey (NOSS). Based on aviation’s Line Oriented Safety Audit (Line Operations Safety Audit (LOSA)), NOSS is designed to capture, and learn from, the threats to safety that arise during everyday operations.
A confidential reporting system can be a useful way to reinforce a positive Safety Culture. Such systems complement mandatory reporting processes, and allow safety lessons to be learnt from occurrences that may otherwise remain unreported.
Although safety occurrences are unfortunate and costly, they are a valuable opportunity for an ANSP to learn about its vulnerabilities. The amount learned from an event is dependent on the quality of the safety occurrence investigation process used, and the investigation team resources.
The team debriefing after an incident is another important way to learn from the event, at the local and organisational levels.
The primary aims of the incident debriefing are to understand what happened, to learn from this, and to implement the lessons learned at team level with the objective of preventing the incident from happening again. Global lessons for the ANSP, or even the industry, may emerge from the debriefing, and should be communicated through appropriate channels.
It is important that the debriefing be conducted as an open and ‘blame-free’ discussion, consistent with a Just Culture philosophy. Each team member should be allowed and encouraged to express their point of view. Feedback to individuals should be constructive - “what would you do differently next time” - not critical or directive (“don’t make that mistake again”).
It may also be that a ‘near miss’ has caused some distress to those involved (or perhaps even people only indirectly associated) which needs to be addressed. For these reasons it is desirable that a team debriefing becomes a routine event after an incident.
Note: Personnel who have been seriously affected by an event should not be required to take part in a team debriefing. Instead, they should be referred to a trained colleague who is able to conduct a formal stress debriefing (e.g. using CISM - Critical Incident Stress Management in ATM).
Just as an organisation can demonstrate wariness as a feature of its Safety Culture, teams and individuals can display wariness at a local level, through their alertness to safety threats.
At a global level, wariness refers to the way an organisation remains constantly vigilant for hazards and potential failures, and prepares for unexpected although unlikely and rare events. It is perhaps one of the more subtle and obscure characteristics of an ANSP, yet one that clearly distinguishes a positive Safety Culture from one that is less mature.
All employees have a role to play in being wary, since by definition, Safety Culture is based on “shared values and norms of behaviour articulated by Senior Management and translated with high uniformity into effective work practices at the front line".
- Safety Culture in ATM
- Solutions:Safety Culture Enhancement Toolbox for ATM
- Just Culture
- Interdependence Between Safety Culture and Safety Management Systems in ATM
- Assessing Safety Culture in ATM
- Toolkit:Systems Thinking for Safety: Ten Principles
- From Safety-I to Safety-II: A White Paper, EUROCONTROL, Sept. 2013
- Systems Thinking for Safety: Ten Principles. A White Paper, EUROCONTROL, August 2014
- EUROCONTROL/FAA White Paper: CEOs on Safety Culture, October 2015
- EUROCONTROL/FAA White Paper: Safety Culture in Air Traffic Management, December 2008
- Safety Culture Enhancement Toolbox (accessible also from the SKYbrary Home Page)
- ^ Gaba, D.M., Singer, S.J., Sinaiko, A.D., Bowen, J.D., & Ciavarelli, A.P. (2003). Differences in safety climate between hospital personnel and naval aviators. Human Factors, 45(2), 173-185.
- The Transition From Event Reprts to Measurable Organizational Impact: Workshop Proceedings Report, Avers et al., FAA, 2014
- Just Culture - Assessing Safety Behaviours 'Best Practice', Austrocontrol, September 2017.