Transcript A stochastic conflict detection model revisited

Safety Culture Process
Barry KIRWAN - EUROCONTROL
[email protected]
European
Organisation for the Safety of Air Navigation
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Real Safety Culture, real safety issues.
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A controller makes a mistake, but no
one sees it. Does he report it?
A supervisor sees ‘cowboy’
behaviour by a controller, but the
supervisor is no longer connected
with the teams. Does he act?
Two Department Heads (Ops & Eng)
know their departments don’t work
well together. Do they ignore it?
The Safety Culture Process
Preparation Meeting (Oct)
HOW
STRONG
IS THE COMMITMENT
SAFETY?
COULD YOUR
ANSP
BE INVOLVED
IN A SERIOUS TO
SAFETY
INCIDENT?
 Launch (Jan)
 Questionnaire (Jan)
 First Diagnosis (March)
 Workshops (April)
Results of a Safety
The
organisation
tries
to
do
more
than
just
I am concerned that equipment, important to
Culture Survey at
6%
17%
 Analysis
&
Recommendations
meet
the
minimum
safety
regulations(G9)
operational safety (e.g. radar) will fail in the near
63% XXXXX 78%
19%
Version: 1.0
19%
future(E12*)
 Presentation
to Management
Date: 3 June 2011
(May)
I amMy
concerned
that
operational
incident will 7% 4% 25%
colleagues
arean
committed
to safety(G4)
23%
89%
happen
in the near future(C3*)
 Report
(June)
52%
Confidential
 Presentation to Staff (June)
Changes to the organisation and ATC system do 4% 11%
14%
My management is committed to safety(G7)
33%
not
increase
safety-related
risks(M18)
 Action Plan (Sept)
81%
56%
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0%0%
3
20%
20%
40%
40%
60%
60%
80%
80%
100%
100%
The Process – High Level
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Decide to embark on the Safety Culture Process
Elect a champion, back the champion
Engage internal stakeholders
Launch the Process
Ensure good participation
Prepare
Expect a mixture of news
• Strengths
• Areas for improvement
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Give feedback to participants
Build on the Results
Launch
Learn
Run
Step 1. Prepare (1/2)
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Consider Benefits & Costs
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Consider Breadth & Timing
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Trusted by both staff & management; visible
management commitment (CEO/Board announcement);
Inform Internal Stakeholders
•
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Participation: ATCOs, Engineers, Managers, All?
Locations: HQ, ACCs, Towers, other?
Other initiatives? Ongoing problems/issues?
Elect Champion & Support Champion
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Better risk picture & management; Staff engagement in
safety vision
Costs of staff involvement (time); External supply costs
Heads of Departments; Staff Committees; Unions; etc.
Step 1. Prepare (2/2)
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Select Approach
• Questionnaire; focus groups
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Select Technique
• Off-the-shelf; Bespoke
• Eurocontrol; Keil Centre; other
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Select Outside Agency
• Eurocontrol; Consultancy; University
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Determine Launch Date
• Best if not during summer period
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Step 2. Launch
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Management Briefing
All Staff Briefing
Multi-Centre
Explain Why, What, So What
Stress independence/anonymity
Practical Points (POCs; Timings)
Survey team familiarisation and
observation, walk-rounds, etc.
Step 3: Running the Survey - The Heart of the Process
Questionnaire
Analysis
Identify Key Issues
Survey the population
1. General section
2. Controllers/Assistants
3. Maintenance/Engineering
4. Managers
Understanding
the Issues
Analysing the Issues
Workshops
Prioritising the Issues
Solution proposals
Feedback to Management & Staff
After the workshops
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Improvement Strategy
Commitment
Teaming
Involvement
SAFETY
CULTURE
Learning &
Reporting
Responsibility
Communications
& Trust
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Below is a list of statements regarding safety issues that are
relevant to your role in the organisation. Please indicate the
extent to which you agree/disagree with each one by circling
one number on each line. We want your opinion about how
your organisation currently works.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Questionnaires
1. Even if some equipment is unavailable, we are still required
to meet our capacity targets
2. The equipment that is available is suitable for my job
3. In ATC everyone knows there is an accident ‘just waiting to
happen’
4. Maintenance staff understand how equipment failures affect
our ability to provide safe air traffic services
5. I trust the ATC procedures that I use in my job
6. Maintenance staff perform sufficient system checks
7. The future plans are adequate for the development of the
ATC service
8. I trust the ATC equipment that I use in my job
9. We openly discuss incidents in an attempt to learn from
them
10. Controllers would never compromise their responsibility
for safety
11. We are expected to be able to handle safety problems
without reducing throughput
12. We are consulted about changes to the technical/
engineering system that impacts on the way we do our work
13. There is pressure to use smaller safety margins than I feel
comfortable with
14. It is possible for operational and technical/ engineering
systems teams to meet together and discuss potential
solutions for past problems
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Comment
Controllers
Engineers
Managers
General
Sample Results: Best 5 items
I have confidence in the
people that I interact with in
3,33,9
my normal working
situation
If I do something wrong, I
can discuss it with my
colleagues without
worrying about the
consequences
Each member of staff has
a responsibility to keep up
with changes to
procedures
92,8
92,9
3,63,6
% unfavourable
94,1
3,62,3
% favourable
Only the Safety Department
1,32
has responsibility for safety
96,7
Only my manager has
12,3
responsibility for safety
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% neutral
0%
96,8
10%
20%
30%
40%
50%
60%
% of respondents
70%
80%
90%
100%
Sample Results: Bottom 5 items
% unfavourable
Even if the system fails, we are
still expected to achieve the
targets that are set for us
% favourable
60,3
Feedback from incidents
comes months or years later
with few recommendations
12,2
53
The other people in the
organization do not understand
our job and the safety roles we
fulfil
15,2
46,4
There is a lack of feedback on
the results of safety initiatives
that we have participated in
0%
10%
20%
35,8
26,1
38,5
38,3
20,9
30%
40%
50%
27,5
31,8
17,9
35,5
We have sufficient safety
experts and support staff in
house
12
% neutral
40,5
60%
70%
80%
90%
100%
Focus Group Process
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4-6 GROUPS (mixed) +
Facilitators
Key issues
• Ensure understanding
• Consider causes and
consequences
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Potential solution paths
Key ways forward
Mode: Facilitated Process
Output: Confidential Report to ANSP
1. ‘Diagnosis’ of ANSP Safety Culture
Results of a Safety
Culture Survey
at
2. Detailed
Results
by Group
& culture
Region
Safety
: qualitative
NAV PORTUGAL
and quantitative assessment
3. Suggested
Ways Forward:
Version:
3.0
Date: 30 April 2007
Quick wins & longer term solutions
Project Coordination:
Sílvia Agostinho da Silva
CIS/DEPSO/ISCTE/PORTUGAL
[email protected]
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ANSP Safety Culture Enhancement Strategy
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Decide the options and the priorities
• Strategic – e.g. safety culture campaigns
• Tactical – e.g. improve computerised incident
reporting system
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Allocate responsibilities & resources
Be realistic about the time it can take to
change culture
Track & Monitor Progress
Communicate, communicate, communicate
Timescale of the Survey Process
Strategic review
2nd Measurement
Mid-term
Review
Improvement
Strategy
Focus
groups
Analysis
Launch
0
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1m
3m
6m
1yr
3 years
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Example ‘Board Level’ Picture
1. Positive safety culture
2. ‘Passion for safety’
3. High Risk Awareness
4. Involvement in Safety
Risk
Awareness
Teamwork
Involvement
5. Pace of change
6. Communications
7. Learning from incidents
8. Trust between Teams
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SAFETY
CULTURE
ELEMENTS
Learning
and Trust
Communications
Commitment
&
Responsibility
Example Recommendations
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Supervisor is a key asset – reassess safety function of
supervisor, especially how to
support safety culture in the shift
‘teams’
Enhance the speed and
transparency in incident feedback
to controllers – and extend the
process to maintenance
engineers
Deal with certain safety ‘hotspots’
identified in the survey
Review OJTI training protocols in
high intensity work situations
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Determine top ten ‘hit-list’ of safety
issues for the organisation
Evaluate extent of ‘workarounds’
Gain more operational involvement
in HAZOPs etc.
Clarify safety responsibilities for all
staff including corporate
management
Prioritise safety resources
Renew Team Resource
Management
Support
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Getting Started
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Technical Support
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EUROCONTROL, CANSO and FAA all
have placed Safety Culture as a strategic
objective over the next 5 years.
Peer Support
•
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EUROCONTROL Safety Team; CANSO;
FAA
Consultancies (e.g. the Keil Centre in the
UK; NLR in Holland);
Universities (various, e.g. Aberdeen [UK],
Lund [Sweden]; Leiden [Holland] etc.)
Continued Support
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White Paper; ‘Brochure’; Safety Culture
Toolbox
EUROCONTROL planning ANSP regional
workshops in 2009 onwards
Summary
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The measurement of safety culture is relatively mature
There is an agreed process: although some individual
tools may differ, they deliver similar results
It is not a painful process
There is support available
More and more European Member States signing up
Questions?
Costs
Safety