RMIT Classification: Trusted

AERO2384 - Aviation Safety & Security Systems

Safety Culture

School of Engineering
Assoc Prof Selina Fothergill

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Human and Organisational Factors

Source: https://www.era.europa.eu/activities/safety-management-system/human-and-organisational-factors-hof_en

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Safety Culture – Learning Objectives

1. Organisational Culture
2. Safety Culture
3. Safety Culture Elements
4. Just Culture (and the culpability matrix)
5. Errors and Violations
6. Improving Safety Culture
7. Measuring Safety Culture

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Safety Culture Case Study – Royal Australian Navy Sea King Accident (2005)

Source: https://www.defence.gov.au/Publications/BOI/SeaKing/Images/FlyingStations.jpg

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Shark 02 - After

Source: https://www.defence.gov.au/Publications/BOI/SeaKing/pdf/chapters/Chapter%206.pdf

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Accident Sequence

Source: https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.researchgate.net%2Ffigure%2FAccident-Sequence-of-Shark-02-
1_fig1_281065556&psig=AOvVaw1bLnU-_rE_1qsusIQOmrlJ&ust=1597740666578000&source=images&cd=vfe&ved=0CA0QjhxqFwoTCLjBxIPuoesCFQAAAAAdAAAAABAJ

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Maintenance Activity Conducted

Source: https://www.defence.gov.au/Publications/BOI/SeaKing/pdf/chapters/Chapter%206.pdf

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Missing Hardware – but how?

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Safety Culture Outcomes

• 256 Recommendations

• 759 Findings

• Widespread changes within the ADF Aviation community

• New Airworthiness Management Structure

• Focus on developing Positive Safety Culture

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Organisational Culture Overlays

National

Professional Organisational

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Characterisations of Organisations
The three characterisations of organisations, depending on how they
respond to information on hazards and safety information:
Pathological — hide the information
Bureaucratic — restrain the information
Generative — value the information

Pathological Bureaucratic Generative

Information Hidden Ignored Sought
Messengers Shouted Tolerated Trained
Responsibilities Shirked Boxed Shared
Reports Discouraged Allowed Rewarded
Failures Covered up Merciful Scrutinised
New Ideas Crushed Problematic Welcomed
Resulting in Conflicting Org Red Tape Org Reliable Org
Sourced from: Registered with eReserve, International Civil Aviation Organization (ICAO), 2009, Safety management manual, pdf, viewed 19 October 2017, <
https://www.icao.int/safety/fsix/Library/DOC_9859_FULL_EN.pdf>, ICAO, Montréal, p. 2-29, Table 2.1 Three possible organizational cultures

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Organisational Culture Overlays

The interactions between the three cultural overlays determine how:

• Juniors will relate to their seniors

• Information should be shared
• How Personnel reacted under demanding operational conditions
• The Organisations reaction to operational errors and non-compliant
behaviours
• How and when the procedures were followed and developed
• How the documentation was prepared, presented and received
• What training was developed and delivered
• How well do the different work groups interact with each other

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Safety Culture Ladder

Patrick Hudson model

G E N E R AT I V E
Safety is how we do
ED business around here
M
F OR PROACTIVE
IN
G LY We work on the hazards that
IN we still find
E AS Y
CR C A L C U L AT I V E L IT
IN BI
We have systems in pace to T A
UN
manage hazards CO
AC
REACTIVE &
T
US
Safety is important. We do a TR
lot every time we have an NG
A SI
accident
PAT H O L O G I C A L C RE
IN
Who cares as long as we're
not caught

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‘The five key ingredients of

an effective safety culture’ Informed Culture
Those who manage and
operate the system have
current knowledge about
the human, technical,
organisational and
Learning Culture environmental factors
that determine the safety
An organisation must
of the system as a whole.
possess the willingness
and the competence to

Effective safety Flexible Culture

draw the right
conclusions from its
safety information
system and be willing to
Reporting Culture

cultures
implement major
An organisation can reforms.
adapt in the face of high- An organisation
tempo operations or climate in which
certain kinds of danger – people are prepared to
often shifting from the report their errors and
conventional hierarchical
Just Culture
near-misses.
mode to a flatter mode.
There is an atmosphere of
trust. People are encouraged
(even rewarded) for
providing essential safety-
related information, but they
are also clear about where
the line must be drawn
between acceptable and
unacceptable behaviour.

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Just Culture

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Safety Policy – Pre-Accident

Keep Navy Safe

1. Effective and inclusive safety culture
2. The use of a system of safety tools
3. The application of risk management principles.

https://www.google.com/url?sa=i&url=http%3A%2F%2Fwww.aero-news.net%2Findex.cfm%3Fdo%3Dmain.textpost%26id%3Dbf9628ac-5226-434b-81c6-
6dff86831119&psig=AOvVaw0OmXMwPJ4vM0qvL2YNlk9l&ust=1597747052846000&source=images&cd=vfe&ved=0CA0QjhxqFwoTCPCRruaFousCFQAAAAAdAAAAABAJ

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Just Culture – Post Accident

To develop a culture that is ‘Just’ it must start with a well

accepted Just Policy or a Safety Policy that covers the
Just Policy elements

Source: https://src.healthpei.ca/sites/src.healthpei.ca/files/srcForms/src_psculture.pdf

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Unsafe Acts

Videos on difference between errors and violations

https://youtu.be/rHeukoWWtQ8

https://youtu.be/4Y5lRR9YK2U

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Unsafe Acts

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Maintenance Error Causal Links

Source: https://www.defence.gov.au/Publications/BOI/SeaKing/pdf/chapters/Chapter%207.pdf, Figure 7.3

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The ‘mental economics’ of violating

Perceived benefits:
• An easier way to working
• Saves time
• More exciting
• Gets the job done
• Shows skill
• Meets a deadline
• Looks macho

Perceived costs:
• Possible accident
• Injury to self or others
• Damage to assets
• Costly to repair
• Risk of sanctions
• Loss of job
• Disapproval of friends/ work colleagues

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Improving Safety Culture

Policy & Risk

Assurance Promotion
Objectives Management

Organise Implement Consolidate Assess the

Change Change Change results

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Safety tools to measure a safety culture

• Safety Culture Surveys

• Key Performance Indicators (Lagging and leading)

• Interviews

• Checklists

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CASA GAP Analysis Checklist

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Creating a Positive Safety Culture Within

Aviation Operations
Some of the basic conditions required for a positive safety culture:
1. Trust
2. A non-punitive policy towards error
3. Commitment to taking action to reduce error-inducing condition
4. Diagnostic data that shows the nature of threats and types of errors
occurring
5. Training in threat conditions, error avoidance, and management
strategies for crews (CRM), and
6. Training in evaluating and reinforcing threat recognition and error
management for instructors and evaluators.

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End of Lecture
https://youtu.be/_TXqes10g0o

Source: https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.anywise.com.au%2Fpost%2F2018-02-15-in-memory-of-shark-02&psig=AOvVaw10-
YZjW4Vc_u_E--NoRqA&ust=1597739104777000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCMjH5ZLooesCFQAAAAAdAAAAABAD

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