Is a just culture the just way to safety intelligence

As of 15 November 2015, EU Regulation 376/2014 requires aviation organisations to report, analyse and follow-up occurrences in civil aviation. Its primary purpose is to improve aviation safety by learning from reported safety risks. The Regulation also provides the basic ingredients for establishing a just culture, in which individuals are encouraged to report actual and potential safety risks.

Have you ever wondered what this means to you? And how this affects you and your organisation?

For some organisations, safety reporting systems have been around since Safety Management Systems became required. For other organisations, ideas about safety reporting systems just substantiate. Since an effective safety reporting system is founded on a couple of essential attributes, it is important to fully grasp them and take them along in the development process.

In several parts, the essential attributes of an effective safety reporting system will be reviewed:

  • Part 1: The context
  • Part 2: Commitment
  • Part 3: Just culture
  • Part 4: Safety reporting system
  • Part 5: Safety reporting system continued
  • Part 6: Safety awareness
  • Part 7: Flexibility in risk management
  • Part 8: To behave or not to behave?

The just way to safety intelligence

So what has just culture to do with safety reporting systems and if this is the foundation of an effective system: how can a just culture be developed and maintained? Let’s start off with the context.

As already expressed by the Regulation, a just culture is an essential element of a broader safety culture, which forms the basis of a robust safety management system. However, for organisations without safety management systems in place, a just culture is just as essential to collect sufficient information from the operational environment.

Trust is the key factor in reporting of actual or potential safety risks. Trust has to do with the presence of a just culture. In a just culture, individuals are encouraged and even rewarded when reporting safety related issues. Reporting of errors is not punished, except in cases of gross negligence, wilful misconduct or criminal acts. A clear distinction is made between acceptable and unacceptable behaviour and this is known to all personnel. When personnel are convinced that their information is treated in a just way, their willingness to share safety information will increase.
This way, an organisation will be better informed of hazards and risks in the operational environment.

When trust is obtained to use the safety reporting system, it is essential to keep this level of trust. Trust is easily lost when one person’s safety information is treated in an unjust way. This will ripple through the organisation, creating serious doubts whether individuals and their reported safety information are adequately protected.

Even when trust in the system is being kept, it is important to keep motivating individuals to report safety issues and share safety information. This may be accomplished by providing regular updates with regard to trend analyses and interventions, and by consulting personnel in the development of interventions to improve safety in the operational environment.

To accomplish this, there is one imperative attribute of a safety culture that even forms the essential foundation of a just culture: Commitment.

In Part 2 of The just way to safety intelligence, it will be explained how safety improvements are driven by Commitment.

 

In Part 1 we started to look at the context in which a just culture can be developed and flourish. Trust was considered to be the key factor, but trust is built on the essential foundation of any safety culture: Commitment.

Commitment reflects the extent to which every level of the organisation has a positive attitude towards safety and recognises its importance. Top management should be genuinely committed to keep a high level of safety and give employees motivation and means to do so as well.

Management commitment to safety is the key factor in a healthy safety culture. One of the most important goals of (top-) management should, apart from making profit, be to keep a high level of safety; in the operations, for the customers, and last but not least: for the employees. Commitment to safety expresses itself in management being accessible to the workforce, willing to release job pressure if safety is at stake, and also in management accepting setbacks and human errors as inevitable; putting everything in place to minimise the chance of such errors occurring. Management commitment to safety should furthermore be projected onto the employees, who, in a good safety culture, have confidence in the management being a good conversation partner and doing everything possible to keep high safety records.

But why is management commitment so important when employees are already safety-minded? Likely no honest individual goes to work in the morning with the intention to create an incident or accident?

Management commitment to safety reflects on the personal commitment to safety of all employees the organisation. This has to do with setting the example: Signals from management easily spread throughout the organisation and are adopted by the workforce. In setting a good example, unsafe behaviour is corrected, but more importantly, safe work practices are recognised and praised. If a good example is set, employees consider safety as a core value, are aware that a high level of safety is essential for the continuity of the operations and, even closer to home, essential for their own health and safety. They will recognise their role and responsibility in ensuring safety, not only for themselves, but also for others, and be aware that they are a link in the chain of the organisation’s processes and that each link is equally important. This means that safety should always been given priority above efficiency and profit, and safety issues, however small, should be considered seriously.

However, in the end, money is the overriding factor when a balance is sought between safety and profitability. How to keep these two balanced? A deep involvement of the safety department in the business processes is highly recommended to achieve this.

The prioritisation of safety is reflected, among others, by the amount of money and effort that is invested in order to maintain and improve the level of safety. Sufficient resources should be provided for safety training, safety investigations, safety initiatives and communication of safety-related information. It is important to communicate about investments made to improve safety, but it is equally important to clearly communicate why investments are not taken or postponed and how safety is still assured.

In Part 3, we take a closer look at a just culture: the next building block in creating a healthy safety culture.

Is a just culture like the old verse says: “Treat others the way you want to be treated”, or is there more to it when a just culture is applied within organisations?

A just culture, in the organisational context, reflects the extent to which safe behaviour and reporting of safety issues are encouraged or even rewarded, and unsafe behaviour is discouraged. This immediately raises the question of what safe behaviour entails. From numerous safety culture assessments it can be concluded that the line between safe and unsafe behaviour is very thin and ambiguous. Mostly, safe behaviour is defined by its opposite, i.e.: gross negligence, wilful violations and destructive acts, and is therefore not rewarded as such. As a result, several tools have been developed to define unsafe behaviour, but no such tools exist to reward the desired opposite, since safe behaviour is the expected standard way of working.

Safety related behaviour should be evaluated in a consistent and just manner. However, what is considered to be just and safe largely depends on individual perceptions. What is considered safe behaviour by an employee in a certain situation and under certain circumstances may be perceived by others as unsafe. This not only applies to the perceptions of operational personnel facing risks during their daily activities, but also to the perceptions of the individual(s) conducting investigations or with the authority to impose disciplinary measures. Therefore, for an evaluation system to be consistent and just, it has to be embedded in the organisation’s safety policy and define what safe and unsafe behaviour entails. When this is clearly communicated within the organisation, all employees, from management to workforce, can be held accountable for their actions.

A safety culture is based on perceptions and a just culture even more so. Even when an evaluation system has been developed for a consistent and just evaluation of safety related behaviour, it should also be applied very carefully, for any perceived flaw in the system will put the entire system and its operators in doubt. The evaluation system intended to evaluate behaviour leading to incidents (better known as incident or accident investigations) should be headed by a trustworthy individual with the required credibility, personal skills and relevant operational experience. If this is not feasible, assistants with the required attributes should be involved in the evaluation process.

A just culture should also consistently be practised according the safety policy. Evaluation of behaviour leading to incidents or accidents should be conducted irrespective of someone’s experience, status, etc. and systematically strive to identify causal factors, which may relate to organisational issues or management decisions. Reporting of errors or unsafe situations should not have adverse consequences for reporters’ career opportunities, but instead be seen as valuable opportunities to learn and improve. Even highly experienced individuals make mistakes and are a valuable asset to involve in the resulting investigation and improvement process from which the entire organisation may benefit.

So is a just culture a culture in which you treat others the way you want to be treated? Partially, but there is more to it. Let’s start to reflect on our view on safe behaviour and strive to transfer our personal lessons learnt to the entire organisation.

In Part 4 of The just way to safety intelligence, the specific building blocks to build a just culture in which lessons learnt can be fully exploited, will be briefly described.

In Part 3 of The just way to safety intelligence we took a closer look at a just culture in which safe behaviour is evaluated by a system embedded in an organisation and how it should be applied by a person or team that has acquired trust and respect from all staff - both management and workforce. In Part 4, we reflect on specific attributes of a safety reporting system that, when well-developed, greatly help the safety manager or department to acquire and keep this essential trust and respect.

In smaller organisations, a safety manager may be regularly seen on the work floor, providing a face to safety and building trust between operational personnel and the safety department. However, in larger organisations, this is nearly impossible due to the multi-faceted activities and operational environments. In such case, a safety reporting system is a great aid to a safety manager. To obtain the highest benefit from such a system, the various elements, or architecture, need proper attention to collect all relevant safety data and to build and maintain a culture of trust.

As stated in the previous part, it is important to develop a reporting policy and procedures, which ensures management commitment, the necessary resources and provides indemnity against legal prosecution. When it comes to resources, roles, responsibilities and tasks have to be defined for management and functioning of any safety reporting system, as well as for who has the authority to impose disciplinary actions when necessary.

After a reporting policy and procedures have been developed, the infrastructure for reporting safety occurrences has to be established . Reporting of safety issues should be a clearly described and easy process, explained to all personnel, safety reports should be professionally assessed and managed, and feedback should be accurate, useful and intelligible to all personnel.

A safety manager can make or break a safety reporting system, but the opposite is also true. As the safety reporting system is an invaluable tool for the safety manager, providing accurate feedback is essential to build and to keep reporters’ trust in the system and those who manage the system. Reporters should receive prompt confirmation that their safety report has been received, understood and further investigated or monitored for trend analysis. Feedback about what corrective actions are taken, of for what reason they are postponed or rejected is equally important. It is essential to provide transparency with regard to the considerations made by the safety department and management.

As stated before, trust is a precondition for a safety reporting system and essential in maintaining the motivation to report. At a higher level, management commitment has to be ensured. To maintain and improve management commitment to safety, management has to be continuously involved in the reporting process to visibly show that they believe in, take part in, and are willing to promote the just culture. Simultaneously, commitment to safety of the workforce has to be ensured by actively involving them in the assessment of safety issues and development of corrective actions.

Although a safety reporting system is a great aid in developing and maintaining trust when well-managed, the system does not replace the safety manager. Safety still needs to get a face, so the safety manager should still regularly be seen around.

In Part 5 of The just way to safety intelligence, we take a closer look on how to obtain the highest benefit from a safety reporting system.

In Part 4 we reflected on specific attributes of a safety reporting system that, when being well-developed, greatly help the safety manager or team to acquire and keep the essential trust and respect that are necessary to create a just culture.

Now let’s assume we have established the perfect just culture: Management and employees are fully committed, safety investments are being made, investigations reveal causal factors, and employees know and agree upon what behaviour is expected and feel rewarded for their commitment and contributions to safety.

Are we there then? Mission accomplished? Not really. A strong basis has been established, but still a lot of work has to be done to keep adequately and accurately informed about present and emerging hazards and risks in the operational environment. Let’s take a look at the system itself.

The safety reporting system has to facilitate collection, management, accurate feedback, analysis and dissemination of safety information. Key to accurate analyses is the information that is gathered in the reporting forms. The purpose of safety reporting – to learn and improve safety – has to be clearly communicated to all employees. This purpose should also be reflected in the fields contained in the reporting forms. When specific data is necessary for analysis purposes, this data should be asked for in the reporting forms. The amount of detail provided translates directly to the amount of detail in the analysis: the well-known ‘garbage in garbage out’ saying applies. A safety manager cannot expect to make analyses beneficial to safety when incorrect or insufficient data is reported.

A next step has been accomplished when the safety reporting system enables the workforce to report situations with a potential safety risk. This way, each employee is being tasked to identify potential safety risks and propose potential solutions. Since the employees are best aware of the risks involved in their daily operations and what is needed to keep these risks at the acceptable level, the most important information is possessed by the employees themselves. By means of a voluntary safety reporting system this information can be obtained and optimally be used. This step enables to take proactive measures to eliminate or mitigate potential safety risks. Additionally, it provides the necessary information to verify if corrective actions are effective and have not created new risks.

Now the foundation is laid for developing the process of transforming operational safety data into safety intelligence. This transformation process is started with the use of three types of safety data: reactive, proactive and predictive safety data.

Reactive safety data contains accident and incident investigations and reporting of safety occurrences. A mandatory safety reporting system is merely reactive, since it is focused on reporting of errors and near-accidents. This reactive way of reporting provides a first source of safety information. Lessons learnt are derived from this data and applied in the aviation system to prevent similar occurrences, incidents and accidents.

Proactive safety data comprises the corrective actions that have been taken following safety reports, audits and surveys. Potential risks are reported, after which this data is fused with audit- or survey findings and further analysed. Potential corrective actions have the objective to prevent occurrences with a worse outcome, and to prevent occurrences that have not happened yet. By means of conducting audits or surveys, shortcomings and potential risks may be detected in an early stage, enabling the aviation system to take corrective actions.

Predictive data does not originate from safety occurrences or shortcomings, but consists of a continuous monitoring process of the operation of the aviation system. This is done, for example, by means of Flight Data Monitoring programmes, continuous safety performance monitoring or operational risk management. Adequate risk management may provide a source of predictive safety data. This way, potential system degradations or risks may be anticipated and timely be controlled or eliminated.

For any organisation or Safety Management System to be well-informed, the safety data extracted from the operational environment has to be fused and transformed into safety information. This means that the data is assessed and analysed on severity and frequency, and that trends are being monitored. The next step is transforming the safety information into safety intelligence. In this step, the safety information is confirmed and further analysed by considering the safety information in the applicable context. For example, additional data requests may be necessary to determine the cause of specific safety occurrences. The last step is to accurately capture the acquired safety intelligence in a database or report to maintain the knowledge and comprehension that has been gained from the safety data for future reference.

The safety intelligence thus created and captured, proves to be invaluable in training and promulgation of safety information to all employees when it comes to dealing with safety issues in their daily work. With this basis of safety intelligence, decisions with regard to safety can be based on factual, historical information and has the safety reporting system evolved into a truly safety intelligence system.

In Part 6 of The just way to safety intelligence, it will be explained how safety intelligence can adequately be used to increase the safety awareness of both management and the workforce.

Aviation is quite a risky business, isn’t it? You voluntarily load yourself into an airtight tube filled with highly combustible fluids, are basically launched into a non-survivable environment some thousands feet above the earth without any hard shoulder to stop when difficulties arise. Yet there are thousands and thousands of people working in this business and even millions of passengers expose themselves to this experience.

For those who know the numbers, aviation is ultra-safe. This, however, may provoke the thought that it is justified to take a less vigilant attitude with regard to safety improvements: It’s safe; lean back and relax.

Now what is required to stay away from complacency and keep working on further safety improvements?

In Part 5 of The just way to safety intelligence we reflected on how a safety reporting system may evolve into a truly safety intelligence system. In Part 6, we will explore how safety intelligence may be deployed to create and keep a vigilant attitude towards risks at all organisational levels.

Healthy safety awareness is a mutual responsibility of the organisation, teams (e.g. flight/cabin crew, ramp workers or departments) and each individual employee. They need and depend on each other to keep aware of the safety risks in the daily operation and to keep and further improve the current level of safety.

For an organisation, its individual employees are an invaluable asset to become and stay aware of the safety risks faced during the daily operations. This is why safety reporting should be as easy and accessible as possible. Individual workers should also be trained for and made aware of their role and responsibility in the process chain to gain the maximum benefit from their risk perception. This way, employees are tasked not only to increase safety in their own operational environment, but also that of their fellow workers.

Individual employees, in turn, need the organisation to mitigate identified risks. The safety officer or department has to compose the total safety picture and present this in such a way to management, that it can be used for safety decision making. To keep motivating individuals to report known, and yet unknown risks, they constantly have to be informed about safety issues and actions taken on their input. And when no incidents occur, borrow incidents from fellow organisations: Why only learn from your own experiences? The learning potential isn’t confined to your own organisation. When incident rates are low; learn from others by applying and tailoring their lessons learnt to your own operation. Can that happen to us and if so, how can we prevent this?

Like with safety data, there is also reactive, proactive and predictive safety awareness. First of all, there has to be awareness of what has happened in the past, what has been done about it and what effect it has had on the organisation and operation. This prevents falling in the same trap of developing safety improvements that have been ineffective in the past. When something happens or a risk is reported, first find out if this is a known or new risk and act accordingly.

Then there is proactive safety awareness: ‘see it coming’. But it is important to know what to look for. For example, rising engine temperatures may be a predictor of an unscheduled engine change, which may be prevented by preventative maintenance.

Predictive safety awareness is a broader way of seeing it coming. For example, an increase in air travel demand due to economic growth provides opportunities for growth in business, but this has timely to be matched with the availability of adequately trained personnel and equipment. Predictive safety awareness requires a long-term safety vision and ambition, and timely safety investments.

In Part 7 of The just way to safety intelligence, it will be explained how organisations and individuals are geared-up for making the necessary adaptations to their operation to adequately cope with the continuous changes in aviation and their associated risks.

In Part 6 we explored how safety intelligence may be deployed to create and keep a vigilant attitude towards risks at all organisational levels. In Part 7, we explain how organisations and individuals are geared-up for making the necessary adaptations to their operation to adequately cope with the continuous changes in aviation and their associated risks.

Resilience and change management: Both buzz words that describe how flexible an organisation may or may not be in changing the way the work is being done. There may be many reasons why an organisation should change its way of working, but since we are safety minded, let’s explore how organisations – large or small – can learn from past experiences and be able to take whatever action is necessary in order to enhance the level of safety.

Numerous safety culture assessments have shown that ‘closing-the-loop’ in the investigation process of reported safety concerns is often lacking.

Like with safety data and safety awareness, there is a reactive, proactive and predictive way to learn and improve. When faced with safety concerns, incidents or accidents, management and employees should take immediate action to prevent such issues to recur. Near misses, whatever form they may take, should also be taken into account and their causes be investigated in order for them not to recur with possibly graver consequences. Installed safety improvements should be evaluated in order to check whether they are indeed effective, and do not imply other unforeseen safety concerns. Numerous safety culture assessments have shown that this last element, ‘closing-the-loop’ in the investigation process of reported safety concerns, is often lacking. Lacking in the sense that such an effectiveness check is not done at all, or not made visible outside the safety department by communicating the effectiveness of safety interventions to all employees. Assessing the effectiveness of corrective actions after implementation provides valuable information about the safety level of the daily operations and provides the opportunity to timely intervene when actions prove ineffective or when other safety issues surface.

Responding to safety issues, incidents or accidents, even when exemplary, is not sufficient for a high level of safety to be reached. Indeed, rather than being reactive, the organisation’s management and employees should be proactive in solving safety problems. Improvements should be looked for and implemented before incidents or accidents occur, and employees should be encouraged to look autonomously for ways to improve safety in their daily work. This not only requires organisational risk management processes to be adequate, but moreover that employees are trained on the basics of risk management and are enabled to perform this in their daily work.

Organisations may temporarily grant employees authority to deviate from normal working procedures within pre-defined boundaries

In an organisation with a good safety culture, it is highly appreciated that employees express and deploy their knowledge and experience to improve safety – not only for themselves, but also for their fellow workers and the customers they serve. Employees should be enabled, motivated and even challenged to suggest improvements with respect to their own job, and even the jobs of their fellow workers. When facing problems, management should not hesitate to assign the right persons with relevant knowledge and experience, even if they are front-line employees, to help solve those problems. When facing problems or safety issues, employees should be enabled, if necessary, to interfere even if these problems or issues are beyond their work area. In this case, their proactive attitude should be appreciated and rewarded accordingly. Organisations may enable employees to do this by temporarily granting authority to deviate from normal working procedures within pre-defined boundaries. Like some deviations from normal flight procedures are made on ‘captain’s decision’, this concept may be applied in a broader way to other employees, provided that they are trained to do this and boundaries are clearly defined.

When this kind of organisational flexibility is managed and facilitated, this is where organisations gain the power to reinforce their learning and improvement capabilities. They get access to a wide spectrum of knowledge and experience from their employees and create the flexibility not only to adequately manage foreseen risks, but also to be prepared for the yet unknown risks.

In Part 8 of The just way to safety intelligence, we will show how all these organisational characteristics and personal attributes shape safe behaviour and how this behaviour can be secured.

Behaviour reflects the extent to which each and every member of the organisation behaves such as to maintain and improve the level of safety. So what makes people to behave unsafe? Or better: what makes people persistently committed to safety in their daily activities?

In the previous parts about safety culture, we have seen that there are a lot of organisational attributes that create a fruitful breeding ground for a safety culture to mature, like regular safety training, safety awareness meetings, report and feedback systems, etc. However, behaviour at the workplace is even more directly affected by several other issues that impact each and every worker on a daily basis.

Keywords that are vital in developing a just culture are Commitment and Trust
A vital ingredient to safe operations is the willingness of employees to behave and perform their job in a safe manner. In the end, it is this personal commitment that is the driving force behind safe behaviour in the daily activities. Personal commitment to safety becomes even more important when the organisational attributes to support and improve safety culture are still sub-optimal. Employees should be aware that risk taking, whether unnecessary or driven by profit or performance concerns, could potentially be very harmful and that it should therefore be reduced to a zero rate. Employees should furthermore be empowered to prevent accidents or incidents, by taking responsibility and undertaking action when needed. This is where training – whatever form it may take – plays a vital role in improving safety. Risk awareness increases with training and when employees are empowered to actually practise what has been trained, their personal commitment to safety is reinforced.

Everybody takes responsibility and can lead the way in safety
Job satisfaction has a direct impact on employees’ safety attitudes in their daily work and is therefore another important requirement to carry out safe operations. Indeed, job satisfaction promotes concentrated behaviour at work, and thereby safe behaviour. It includes a good physical and mental state during normal working periods, a good contact with colleagues, and an adequate job pressure, which is, amongst others, assured by a sufficient size of the staff. Work should be appreciated in an adequate manner by the employees’ foreman or supervisor as well as by their colleagues. This will promote the job satisfaction, hence safe operations.

The actual working space also has great influence on behaviour: employees should have access to the equipment necessary to perform their job in a safe manner. The equipment should be in a good condition, and adequate training to use the equipment should be given. Also, safety equipment should be available at all times. Provision of adequate resources increases motivation and personal commitment to safety.

In this series of articles, we have skimmed on the various dimensions of safety culture. However, as not only national cultures differ, organisational cultures differ even more so. Therefore, each organisation needs a dedicated and tailored approach in assessing and improving its safety culture. Remember that the hardest part of any safety culture journey to improvement is taking that first step.

When working on the development of a safety culture, one should be very aware of the fact that safety culture is learnt by socialisation. Working in isolation, independent of others, does not make a safety culture. As stated in previous articles, safety culture has to do with leadership – setting the example – showing how it is being done. This applies to managers, but similarly to each and every individual employee, including the just arrived temporary worker. Setting the example creates a culture in which safe behaviour is expected and encouraged mutually amongst employees, which results in the acquirement of colleagues’ respect. When faced with unsafe operations, employees are encouraged to stop and report those and violations of procedures and regulations are effectively discouraged. This way, everybody takes responsibility and can lead the way in safety.

The hardest part of any safety culture journey to improvement is taking that first step

Has the message come across in this series of articles on just culture? When we revert to the original question: Is a just culture indeed the just way to safety intelligence, the answer is: Yes, but there are more essential building blocks needed to construct a mature safety culture. Keywords that are vital in developing a just culture are Commitment and Trust. If driven by commitment, a just culture becomes the artery feeding the safety culture: the very heart of your organisation.