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Safety Culture in ATM
From SKYbrary Wiki
Safety Culture represents the priority given to safety at all levels in the organisation, and reflects the real commitment to safety. It is the way that safety is perceived, valued and prioritised in an organisation.
Safety Culture is seen as fundamental for good safety performance in a number of industries and ATM is no exception.
Since Chernobyl nuclear reactor disaster in 1986 where “Safety Culture” term was first applied, the use of the Safety Culture concept has spread to other industries including Oil and Gas, Chemical, Rail, Aviation, Medical, and Air Traffic Management (ATM), where it has recently been applied to at least partly explain both the Überlingen and Milan Linate accidents.
Air Traffic Management (ATM) is a very safe industry - both in terms of quantitative measures such as safety occurrence (accident and incident) rates, and qualitative measures such as the perceptions of the travelling public. However, the industry is currently expanding to cope with increased levels of traffic and this is coupled with fundamental objective to improve further its safety performance.
Reason (2000) proposed that an organisation’s Safety Culture takes on a profound significance at the point where accident rates reach a “plateau”, i.e. where negative outcome data “bottoms out” at some asymptotic value. In order to go beyond this “low but (seemingly) unassailable” plateau and to continue improvement in safety performance, it is necessary to address the hearts and minds of the management and workers (Lee, 1998).
Thus, the ATM system needs to understand how a negative Safety Culture can be a threat, and how it can be managed. Just as the focus in safety occurrence investigation has moved from operator error to systemic failure in recent years, the concept of Safety Culture considers the critical importance of management and individual actions regarding safety, based on their collective values, beliefs and behaviour.
Safety Culture Model in ATM
Researchers and practitioners have proposed numerous Safety Culture models in recent years. The model presented below includes several dimensions on which an organisation’s Safety Culture can be defined and evaluated.
Reason (1997) and Hudson (2003) suggest that an organisation's Safety Culture is defined by the extent to which it is:
- Informed: Managers know what is going on in their organisation and the workforce is willing to report their own errors and near misses.
- Reporting: The organisation encourages employees to divulge information about all safety hazards that they encounter.
- Just: The organisation has a ’just and fair' approach to errors, but requires individuals to be accountable and applies appropriate penalties to unacceptable actions (violations). (See Just Culture)
- Flexible: Such organisations reflect changes in demand, providing both high tempo and routine modes of operation.
- Learning: Organisations are ready to learn and improve, and have the will to implement reforms when required.
The theoretical background underlying the EUROCONTROL Safety Culture Model (See Figure 1) is based on a dynamic definition of Safety Culture, which embodies three major questions representing core dimensions of Safety Culture:
- How committed are we to safety?
- How are we involved in safety?
- How do we learn?
Steps for Changing Safety Culture
Managing any significant change within an organisation - and all the more so a cultural change - implies to organise and follow some specific steps:
- Developing a clear vision, showing not only the direction of the change, but also the underlying values
- Creating the right climate for change: establish a need for it, a sense of purpose and urgency
- Sharing the vision with employees, clearly communicating the vision
- Not permitting roadblocks against the vision
- Empowering people to act and clear obstacles. Employees should feel trusted by the management
- Building a coalition of driving forces
- Setting the relevant human resources: people need the time and space in their work schedules to be able to work on the changes
- Setting the plan and the agenda, including short-term wins
- Coordinating activities.
- Implementing intentions. It is important that visible changes occur in operational activities as quickly as possible
- This will require behaviour changes at all levels of the organisation, not just at the workplace (behaviour modification is unlikely to be successful unless the job environment and organisational factors are also changed).
- Intentions are implemented and transformed through time, and can lead to new strategic changes
- Frequent updates about change programs.
- Consolidating first outcomes and keeping moving
- Not declaring victory too soon
- Securing short-term wins
- Anchoring the change
- Follow-up programme
- Safety Culture
- Just Culture
- Safety Culture Enhancement Toolbox for ATM
- Interdependence Between Safety Culture and Safety Management Systems in ATM
- Assessing Safety Culture in ATM
- Improving Safety Culture in Air Traffic Control
- Human Error in Aviation and Legal Process
- [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 for ATM (accessible also from the SKYbrary Home Page)