Safety Culture

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Safety Culture

• Robert Helmreich, Ph.D.
• The University of Texas
• Human Factors Research Project
• FAA Risk Management Symposium
• Baltimore
• August, 2003

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What is Culture?

• Culture is the values, beliefs, and behaviors
  that we share with other members of groups
• Culture binds us together as a group
• Culture provides cues and clues on how to behave
  in normal and novel situations
• Short definition of culture The way we do things
  here!
• Culture is a factor in accidents and incidents in
  aviation!

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Cultures Consequences

• Culture influences how juniors relate to their
  seniors
• Unwillingness to speak up vs. assertive
• Culture influences how information is shared
• Use of direct versus indirect speech
• Culture influences attitudes regarding stress and
  personal capabilities
• Culture influences adherence to rules
• Culture influences interaction with computers and
  technology

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Our knowledge of culture comes from research into
how organizations function and teams
functionOur research is non-jeopardy. It
protects the identities of crews and organizations
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Three Cultures

• National culture
• The shared components of nationality including
  norms, attitudes, and values
• Professional culture
• Norms, attitudes, values and practices associated
  with being a pilot or doctor or nurse
• Organizational culture
• The norms, attitudes, values, and practices of an
  airline or hospital or organization

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National Culture

• Power Distance (PD)
• In High PD cultures
• Status determines power
• Juniors do not question superiors
• Leaders may be dictatorial
• Many Latin and Asian cultures are high PD
• Australia and Scandinavia are low PD
• The U.S. is intermediate

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Organizational Culture

• An organizations culture reflects
• Values regarding error, blame, and punishment
• Openness of communications between management and
  pilots
• Level of adherence to regulations
• Level of commitment to safety
• Pilots level of trust of management

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Organizational Culture and Safety

• Investigation of air crashes shows poor
  organizational culture to be a precursor of
  disaster
• Lack of safety concerns
• Operational pressures
• Poor leadership
• Conflict with management
• Negative organizational climate
• Morale/job satisfaction

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Professional Culture

• Pilots have a strong professional culture with
  positive and negative aspects
• Positive
• Strong motivation to do well
• Pride in profession
• Negative
• Sense of personal invulnerability

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Personal Invulnerability

• The majority of pilots and doctors in all
  cultures agree that
• their decision-making is as good in emergencies
  as in normal situations
• their performance is not affected by personal
  problems
• they do not make more errors under high stress
• true professionals can leave behind personal
  problems
• All of these are not true!

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Safety is the Fourth Culture
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What is a Safety Culture?

• A culture committed to proactive safety
  activities
• A culture that recognizes the inevitability of
  error and learns from it
• A culture that is non-punitive

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You need data to assess a safety culture!We
collect data in the framework of the University
of Texas Threat and Error Management Model
(UT-TEMM)
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Data for a Safety Culture

• Accident investigation
• Incident reports
• Data slanted to events resulting from system and
  flight crew failures
• Line checks
• Data show crew proficiency and procedural
  knowledge
• Flight Data Recorders FOQA
• Data show what happened in terms of flight
  parameters
• Observing normal flights Line Operations Safety
  Audit (LOSA)
• Gives data on why things happen and how they are
  managed
• Provides a more realistic baseline of safety

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Line Operations Safety Audit (LOSA)

• LOSA Jump seat observations of flight crew
  performance during regular scheduled flights
• Observers unobtrusive collecting data not
  participating in flight
• Team of observers from different backgrounds
• Line pilots / Union representatives
• Check airmen
• Safety and Training pilots
• UT observers
• All data are DE-IDENTIFIED and CONFIDENTIAL
• 18 LOSAs conducted targeting threat and error
  management)

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Threat and Error Management LOSA (1997-2003)

• Continental Latin America
• Continental Express
• Air New Zealand
• Air Micronesia
• Continental
• Delta
• USAirways

• Cathay Pacific
• EVA Air
• Uni Air (Taiwan)
• Frontier
• QANTAS
• Braathens
• Singapore
• Air New Zealand (repeat)

2,000 flight segments. All foreign carriers are
U.S. codeshares
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University of TexasThreat and Error Management
Model (UT-TEMM)

• The Threat and Error Management model was derived
  from LOSA data and guides further refinement.
• The model is being used by airlines as a
  framework for analysis of incident and ASAP data
• IATA is using it as the framework for analysis of
  worldwide accidents and incidents

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Overt Threats

• Adverse weather
• Terrain
• Traffic
• Airport conditions
• A/C malfunctions
• Automation events
• Communication events

• Operational time pressures
• Non-normal operations
• ATC commands / errors
• Cabin events / errors
• MX events / errors
• Dispatch events / errors
• Ground crew events / errors

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Latent Threats

• Aspects of the system that predispose the
  commission of errors or can lead to undesired
  aircraft states

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Latent Threat Examples

• Inadequate management oversight
• Inadequate regulatory oversight
• Flawed procedures
• Organizational culture and climate
• Scheduling and rostering practices
• Crew fatigue
• Performance assessment practices
• Inadequate accident and incident investigation

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Threat and Error Management Model
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Three Critical Factors in Safety

• Human limitations and error
• Teamwork
• Interface with technology

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Human Limitations Lead to Error

• Limited memory capacity
• Limited processing capacity
• multi-tasking capability
• Limits imposed by stressors
• tunnel vision
• Limits imposed by fatigue and other physiological
  factors
• Poor group dynamics
• Cultural influences

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Why Teamwork Matters

• Most endeavors in medicine, science, and industry
  require groups to work together effectively --
  teamwork
• Failures of teamwork in complex organizations can
  have deadly effects
• More than 2/3 of air crashes involve human error,
  especially failures in teamwork
• Professional training focuses on technical, not
  interpersonal, skills

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Getting the diverse people in aviation to work as
a team is like herding cats
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• Dealing with technology can lead to error

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Newer technology doesnt eliminate error
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Nor does even newer technology
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Safety CultureSurvey Data and Threat and Error
Management
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Forming a Safety Culture Scale

• Pilots observed in LOSA also completed a survey
  with items from the UT Flight Management
  Attitudes Questionnaire
• Items related to organizational culture regarding
  safety were summed to form a Safety Culture Scale

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Safety Culture Scale Items
The managers in Flight Operations listen to
us and care about our concerns.
.69
My suggestions about safety would be acted upon
if I expressed them to management.
.70
Management will never compromise safety concerns
for profitability
.62
.
Safety Culture
I am encouraged by to report any unsafe
conditions I observe.
.65
I know the proper channels to report my safety
concerns.
.42
I am satisfied with Chief Pilot and Assistant
Chief Pilot availability.
.50
My suggestions about safety would be acted upon
if I expressed them to management.
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Safety Indices
 

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Pilot Perceptions of Safety Culture
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Pilot Perceptions of Safety Culture
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Building a Safety Culture What Organizations
Can Do

• Define a clear policy regarding human error
• Accept error but not intentional non-compliance
• Revise procedures where appropriate
• Use confidential reporting systems to uncover
  threats (ASAP)
• Analyze events using TEMM
• Provide formal training in threat and error
  management CRM as Threat and Error Management

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An Expanded Definition of CRM
Sixth Generation CRM
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Training Topics

• Human limitations as sources of error
• The nature of error and error management
• Culture and communications
• Expert decision-making
• Training in using specific behaviors and
  procedures as countermeasures against threat and
  error
• Briefings
• Inquiry
• Sharing mental models
• Conflict resolution
• Fatigue and alertness management
• Analysis of incidents and accidents
• both positive and negative aspects

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• The University of Texas
• Human Factors Research Project