Safety Culture: Can we improve it?

1. Safety Culture: Can we improve it? Barry Kirwan EUROCONTROL

2. Developing Change Proposals • Changes that are effective in the organisation concerned • Changes which are sustainable • Changes which other ANSPs can learn from Safety Culture in European ATM

3. Safety Culture Progress in AVINOR Chief executive ANS Knut Skaar

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. ‘Pillars’ of Safety Culture (James Reason) Just Culture Reporting Culture Informed Culture Flexible Culture Learning Culture Safety Culture in European ATM

8. AVINOR Approach, Post-Survey Dialogue, Involving all Personnel Improved Information Flow Just Culture Reporting Culture Building Competence Informed Culture Understanding Regional Differences Flexible Culture Better Risk Picture Re-assessing Priorities Learning Culture 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? ? ? ? ? ? ? Safety Culture in European ATM

11. How much can we change in 2 -3 years?

12. Safety Culture – Second time around Kjersti 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 Safety Culture in European ATM

16. Reporting & Learning Increases in favourable responses scores for items included in both the 2007 and 2009 survey 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 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!” Safety Culture in European ATM

23. Can other ANSPs repeat this progress?

24. Meeting with Users Safety Culture at NAV PORTUGAL

25. Brest Gander Shanwick Madrid New York LISBON FIR SANTA MARIA OCEANIC FIR Casablanca Canárias Sal Piarco Airspace controlled by NAV Portugal, and adjacent FIR’s Safety Culture in European ATM

26. Target Level • of Safety • Organization • Acountabilities • Safety Letter • Voluntary • Reporting • Presentations • and Courses Safety Management Safety Policy and Principles Safety COMMUNICATION and Training • Safety Analysis • Model, • Statistical • Analysis of Radar • Information. • Safety Indicators • Classification • Risk Analysis • Schemes • Safety surveys • Safety audits Safety Management Tools Safety Assessment Methodology SAFETY CULTURE SURVEYS Safety Management Safety Culture in European ATM

27. NAV Portugal SMS Guidelines for the Safety Culture’s evaluation. Safety Culture in European ATM

28. A Tale of Two Surveys (2007) Independent Surveys Results of a Safety Culture Survey at NAV PORTUGAL Version: 3.0 Date: 30 April 2007 Safety culture : qualitative and quantitative assessment Similar Results & Insights Project Coordination: Sílvia Agostinho da Silva CIS/DEPSO/ISCTE/PORTUGAL silvia.silva@iscte.pt Safety Culture in European ATM

29. NAV-P Strong points • High concern with safety • Participants’ declared values in line with the company's safety policy • 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    • Very positive perceptions of the safety climate in the working groups, in relation to actions by both management and colleagues. • Perception that all staff are involved in safety. • Satisfaction with safety Safety Culture in European ATM

30. Areas for Improvement 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 Safety Culture in European ATM

31. Reducing NAV-P’s Negative Safety Culture ‘Footprint’ Safety Culture in European ATM

32. Regional Workshops

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. Safety Culture in European ATM