An Honest Approach To Safety
go The pilot makes a mistake as he comes in to land. He has followed established procedures and practices with perfect accuracy, but neither he nor his company has ever flown to this airport before. Something unforeseen – by the pilot and by the procedures – catches him off-guard. With his skill and experience, he quickly manages to correct the error and land the aircraft safely. None of the passengers were ever aware of a problem. The co-pilot does not report the incident, not wanting to cause trouble for his colleague. The pilot himself says nothing to his employers, fearing he would be criticised (or worse) for the mistake, although privately he feels the standard procedures were inadequate. The next week, when he hears that a tragic accident has occurred at the airport, the pilot simply thinks – ‘I could have stopped that happening.’
There is a generally accepted theory in aviation that an increase in the amount of reporting of safety-related issues leads directly to an increase in levels of safety. The logic is both simple and reasonable: if you can be aware of potential and actual compromises in safety at the individual level, then you can address them at the organisational level. In fact, the theory is accepted much further afield than aviation alone, from the nuclear industry to medicine, and its roots belong in studies into safety in the Detroit motor industry of the 1930s.
To turn this theory into practical reality, however, the implementation must be part of an organisational culture that supports and encourages honest reporting. For this reason, the concepts of ‘open’ and ‘no-blame’ cultures have come into existence. These cultures seek to assure potential reporters that the organisation will look well beyond the immediate circumstances of a safety significant event and will not respond in a punitive manner. The intention is for honesty, trust and respect to allow the free flow of safety-related information around the organisation. Everybody wins.
In line with current safety management thinking, London Executive Aviation (LEA) has amended the basic ‘open’, ‘no-blame’ culture. We attempt to define a line between acceptable and unacceptable actions or activities and to state that, in certain circumstances, there may actually be a need for punitive action. Negligence and deliberate violations cannot be tolerated. The result is a ‘just’ culture.
One of the main challenges to LEA in implementing this culture has been to draw this line clearly and accurately. Firstly, the procedures set out to be followed in the normal running of all areas of the operation must be sufficiently unambiguous to avoid misinterpretation or abuse, but flexible enough to cope with the regular stream of new situations and challenges that we face. In this way, unacceptable behaviour can be identified when compared to the template of standard procedure. Better still, such behaviour can be more easily avoided in the first place.
Secondly, when dealing with reported safety significant events, the procedures to be followed, from initial reporting through investigation to conclusion and action, must be properly established, understood and familiar at all levels of the company. In this way, a company-wide understanding of ‘just’ is reached. Crucially, the reporting system is most likely to be used by individuals if they are working within a process that they understand and support and over which they have some control.
Thirdly, a means has to be found to determine whether the root cause of a safety significant event is systemic and therefore based on the inadequacy or failure of an established system or procedure. If so, there must be an acceptance of this fact at a senior level of the company. The perception that a company might blame a systemic failure on an individual rather than the organisation is an immense barrier to true belief in a ‘just’ culture.
At LEA, our flight safety officer, Nick Attah, who is also a company Line Pilot, oversees our ‘just’ culture processes. He says: “There may have been a poor perception of the reporting culture in commercial general aviation in the past but that image is no longer accurate. The management of LEA has introduced a private and secure website for our air safety reports and the effort has proven very worthwhile. Our safety culture continues to evolve. Currently, our safety reports are highly reactive in that they are mainly responses to past events but we want to see more reports looking forward to what might go wrong (or right!) under a given set of circumstances in the future.”
Nick is right. If there are shortcomings in our standard procedures, we want to see them highlighted and corrected. Our aim therefore is proactive and predictive reporting – prevention rather than cure.
An ever-increasing number of people are now confidently using the safety reporting system at LEA. As a result, real change is being effected. Staff at all levels know that a ‘just’ culture is the best way forward to achieving the most important goal in aviation – safety.
here Article written by Patrick Margetson-Rushmore
Originally published in P1
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