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The European Organisation for the Safety of Air Navigation
Safety Culture: Can we improve it?
Barry Kirwan
EUROCONTROL
Safety Culture in European ATM 2
Developing Change Proposals
• Changes that are effective in the organisation concerned
• Changes which are sustainable
• Changes which other ANSPs can learn from
The European Organisation for the Safety of Air Navigation
Safety Culture Progress in AVINOR Chief executive ANS Knut Skaar
Safety Culture in European ATM 4
Reasons for Focusing on Safety Culture
• Flight-safety as a quality mark on our product
• Goal; no accidents and fewer serious incidents with ATM contribution
• Lessons learned from other industries• The situation in Avinor when returning as
as chief executive for ANS• The benefit of working with the • elements of Safety Culture.
Safety Culture in European ATM 5
Advancing Safety Culture in Avinor
• Feb 07- Survey
• Mar 07- Workshop
• What do we do with the results?
• Implementing measures in the areas that was identified as challenges and
• Building a Safety Culture campaign
• Oct 07- Roadshow (23 ATC units/11 CNS regions- some combined)
• Jan 09 - Summary after the Campaign, implement necessary changes
• April 09- New Survey.
Safety Culture in European ATM 6
Example High Level Insights from the Survey Process
• Incident reporting ‘impediments’, some easy to fix
• Significant regional/individual variations in attitudes to safety
• ‘Formal’ risk picture, and actual risk picture not the same: some vulnerabilities were obscured
• Talking with staff raised as many solutions as problems
• Need to talk to the whole organisation, not just controllers.
Safety Culture in European ATM 7
InformedCulture
Just Culture
ReportingCulture
Learning Culture
FlexibleCulture
‘Pillars’ of Safety Culture (James Reason)
Safety Culture in European ATM 8
InformedCulture
Just Culture
ReportingCulture
Learning Culture
FlexibleCulture
AVINOR Approach, Post-Survey
Dialogue,Involving allPersonnel
ImprovedInformation
Flow
Building Building CompetenceCompetence
UnderstandingRegional
Differences
Better Risk PictureRe-assessing Priorities
Safety Culture in European ATM 9
Safety Culture Campaign – ANS Roadshow
Safety Culture in European ATM 10
What I Want to Know as Chief Executive...
• Do our ATCOs and Technical staff come to work aiming to deliver a safe service to the customers?• Where can we improve?
• Do we have the right competencies and attitudes
• Correct risk picture?• All the vulnerabilities of our
system – • Exercising sound judgement?
The European Organisation for the Safety of Air Navigation
How much can we change in 2 -3 years?
Safety Culture in European ATM 12
Safety Culture – Second time aroundKjersti Disen
Avinor
Safety Culture in European ATM 13
Safety culture assessment second time around
• History• First safety culture assessment 2007• Safety culture “Roadshow”• Second safety culture assessment 2009• Way forward
Safety Culture in European ATM 14
Improvement Areas
• Exercising priorities• Improving feedback after reporting• Team-meeting places• Improve management of change• Relation to regulator.
Safety Culture in European ATM 15
Second Safety Assessment – 2009 Number of responses
310
482
0
100
200
300
400
500
600
2007 2009
Number of responses
82
117
2349
129
3547
En-route controllers Approach controllers Tower controllers
Assistant controllers Engineers Managers
Other
Safety Culture in European ATM 16
Reporting & Learning
Increases in favourable responses scores for items included in both the 2007 and 2009 survey
53,168
4672
65,380,3
0 10 20 30 40 50 60 70 80 90
Lessons learned from incidents are published in a de-identif iedmanner in a new sletter or similar document (G29)
People in this organization share information in order to keepthe organization w orking properly (G19)
People understand the need to report incidents in order toidentify trends and make changes to the system if required
(G24)
2007 2009
Safety Culture in European ATM 17
Communication
Increases in favourable responses scores for items included in both the 2007 and 2009 survey
Safety Culture in European ATM 18
Second Safety Assessment – 2009
0
10
20
30Responsibility
Commitment
Communication
TrustReporting & Learning
Teamwork
Involvement
2007 2009
Safety Culture in European ATM 19
Improvements
• Committed and listening executive team • Capable and competent safety team• Empowerment of staff to take safety seriously• Safety incident reporting system capable of
handling and feeding back to staff• Top down communication related to safety.
Safety Culture in European ATM 20
Challenges• Large distributed organisation• Resources remain constrained• Standardising performance of supervisors• Communication challenges
• Feedback of incident reports – still…• Communication channels for engineers/ATSEPs• Site wide communication events• Sharing operational information between units.
Safety Culture in European ATM 21
Way Forward
• Conclude the ”roadshow” • Activities to address the challenges identified• Launch a second ”roadshow” • Improvements to occurrence investigation and
lessons learnt • SMS-training • Regular safety culture assessments.
Safety Culture in European ATM 22
Conclusion
• Very positive experience – especially the “roadshow” • Assessment
– worthwhile!• Most important aspect
– MANAGEMENT COMMITMENT!
“The good results give us motivation to continue the work
on improving the safety culture in Avinor!”
The European Organisation for the Safety of Air Navigation
Can other ANSPs repeat this progress?
The European Organisation for the Safety of Air Navigation
Meeting with Users
Safety Culture at Safety Culture at NAV PORTUGALNAV PORTUGAL
Safety Culture in European ATM 25
MadridMadridMadridMadrid
CasablancaCasablancaCasablancaCasablanca
CanáriasCanáriasCanáriasCanárias
ShanwickShanwickShanwickShanwickGanderGanderGanderGander
New YorkNew YorkNew YorkNew York
PiarcoPiarcoPiarcoPiarco SalSalSalSal
SANTA MARIA SANTA MARIA
OCEANIC FIROCEANIC FIR
SANTA MARIA SANTA MARIA
OCEANIC FIROCEANIC FIR
LISBO
N FIR
LISBO
N FIR
LISBO
N FIR
LISBO
N FIR
BrestBrestBrestBrest
Airspace controlled by NAV Portugal, and adjacent FIR’s
Safety Culture in European ATM 26
Safety ManagementSafety ManagementSafety ManagementSafety Management
Safety Management
Safety Safety PolicyPolicyand and
PrinciplesPrinciples
Safety Safety PolicyPolicyand and
PrinciplesPrinciples
SafetySafetyAssessmentAssessmentMethodologyMethodology
SafetySafetyAssessmentAssessmentMethodologyMethodology
SafetySafetyManagementManagement
ToolsTools
SafetySafetyManagementManagement
ToolsTools
SafetySafetyCOMMUNICATIONCOMMUNICATION
and and TrainingTraining
SafetySafetyCOMMUNICATIONCOMMUNICATION
and and TrainingTraining
•Target Level of Safety•Organization•Acountabilities
•Safety Letter•Voluntary Reporting•Presentations and Courses
•Classification•Risk Analysis Schemes•Safety surveys•Safety audits
•Safety Analysis Model,•Statistical
Analysis of Radar Information.•Safety Indicators
SAFETY CULTURE SURVEYSSAFETY CULTURE SURVEYS
Safety Culture in European ATM 27
NAV Portugal SMSNAV Portugal SMS
Guidelines for the Safety Culture’s evaluation .
Safety Culture in European ATM 28
Results of a Safety Culture Survey at NAV PORTUGAL
Version: 3.0Date: 30 April 2007
Safety culture : qualitative and quantitative assessment
A Tale of Two Surveys (2007)
Project Coordination:Sílvia Agostinho da Silva
CIS/DEPSO/ISCTE/[email protected]
Safety Culture in European ATM 29
NAV-P Strong points
1. High concern with safety2. Participants’ declared values in line with the
company's safety policy3. NAV safety climate very positive, characterised by a
perception that safety objectives and rules are valued, that work is conducted safely even under pressure, and that lessons are learned from accidents at work
4. Very positive perceptions of the safety climate in the working groups, in relation to actions by both management and colleagues.
5. Perception that all staff are involved in safety.6. Satisfaction with safety
Safety Culture in European ATM 30
Improved change management
Management leadership on ‘learning not blaming’
Sharpening the focus of the incident reporting and learning process
Better communication on the role of the Safety Department
A task force to consider the best ways to manage safety in high capacity situations
Areas for Improvement
Safety Culture in European ATM 31
Reducing NAV-P’s Negative Safety Culture ‘Footprint’
0,00
5,00
10,00
15,00
20,00
25,00
30,00
35,00
40,00COMMITMENT
COMMUNICATION
INVOLVEMENT
REPORTING & LEARNINGRESPONSIBILITY
TEAMWORK
TRUST
2007
2009
The European Organisation for the Safety of Air Navigation
Regional Workshops
Safety Culture in European ATM 33
Regional Workshop - 14/15 December Paris
Who Attended• ROMATSA
• NATS
• BELGOCONTORL
• AVINOR
• ENAV
• SLOVENIA CONTROL
• IAA
• NAV-P
• ARMATS
• MUAC
• EUROCONTROL
Safety Culture in European ATM 34
Regional Workshop - Knowledge Sharing
Agenda• ANSP Presentations
• 6 ANSPs shared safety information
• Workshops
• Learning from incidents
• The role of the Supervisor
• Just Culture
• Communication
Safety Culture in European ATM 35
Workshop – Output
Supervisors • Few ANSPs have defined roles for
Supervisors
• Not management – Not Controllers
• Can make a bad day a lot easier
• Can make a bad day a lot worse
• Large variation between supervisors
• Define competencies – behaviour based
• Use to create recruitment profile
• Co-locate with Engineering supervisor
• Use 360 degree feedback to address performance issues
• Build in Safety Responsibilities
Safety Culture in European ATM 36
Regional Workshop - Deliverables
Safety Culture in European ATM 37
Conclusions
• The approach can improve safety culture, both at a general level, and at a more ‘tactical’ level.
• A light ‘peer pressure’ is emerging in Europe, with a sharp increase of participating countries in 2010.
• This is at least in part due to ANSPs sharing the experience that safety culture is not ‘fluffy’ and vague, but can in fact fix real problems and improve safety and safe performance.
• We’re all trying to learn how to do it better.