Friday, June 1, 2018

There Is No SMS Without A Just Culture

There Is No SMS Without A Just Culture

Post by CatalinaNJB

A safety management system cannot exist without a just culture since a non-just culture in itself is an opposition to forward looking accountability. Not only does a non-just culture oppose forward looking accountability, but it also opposes the principles of continuous safety improvements. In a traditional safety culture, safety is a mandate established by senior management and demanded that all personnel strictly follow these mandates. Aviation accidents are still classified as a failure to comply with regulations, policies or procedures. The conclusions are often that If only those pilots had complied with regulations, policies and processes there would not be a single aviation accident anymore.  Well, we know that’s not true. In 1956 and the Grand Canyon disaster both Captains of both airlines were following regulations, policies and procedures and they ended up in a mid-air collision. On the other hand, if KLM 4805 had continued their first takeoff roll without a clearance, is there a possibility they could have cleared Pan Am 1736? There are times when following the rule could have avoided an accident, but there also are times when not following the rule prevents an accident. Regulatory requirement serves a different purpose, or role, than operational safety. A finding that following regulations, policies and processes would have prevented an accident is not a fact of the true root cause. A true root cause analysis identifies what was done rather what was not done.
Just culture is to line elements for comprehension and continuous safety improvements.

An enterprise may conduct a self analysis of their own just culture. There are several variations of valuable just culture assessments tools available for an enterprise to conduct evaluation. A just culture self-evaluation is more than tick the correct boxes. It is to find the true culture in the organization. With a fully operational safety management system an operator is expected to operate within a just culture. It becomes a failure to the SMS unless the culture is present. An operator could believe that they are operating within a just culture while there is no data to support their opinion.  A just culture is not the same as a non-punitive culture, but a culture that is just in the assessment of root causes. A non-punitive culture is in itself a hazard to aviation safety when it is not incorporated in a just culture. The four parameters of a just culture are trust, learning, accountability and information sharing. When the system of just culture is effective the outcome is comprehension of SMS and continuous safety improvements.

Visualizing a just culture is to line up six dices in a row where all dices are displaying equal numbers. SMS process implemented needs one process to generate trust, one process to instill learning, one process to accept accountability and one process to share information. When these four processes are established, the effectiveness is shown in the output of system comprehension and continuous safety improvements.

A great safety change today could be obsolete over time.
In a non-just culture there is only one dice; the pilot. When things go wrong the pilot is blamed. By improving the process, a second dice was added; the nav-aids. Eventually other processes are put in place and with the third dice; the air traffic controller. In this example of a just culture, these are the three first elements of the culture, where the pilot is trusted the authority, the nav-aids provide guidance and support, the third is to place accountability on ATC, in that ATC has the authority to maintain safe air to air and air to ground separation. The fourth element of a just culture is to share this information by reporting of hazards, incidents accidents and safety concerns. Sharing this information improve individual comprehension of the SMS systems and how implemented improvements equals continuous safety improvements.

A just culture is expected to eliminate accidents. Some might say that it’s not possible to eliminate all, but if one flight can be safe, what are the reason for the next flight not to be safe. In a true story the safety process did not include all four elements with a fatal outcome. A person had sat down in front of a fire-trucks door and dozed off. The fire department was called out, opened the doors and run over the person sitting there. The fire department process had placed the role of safety on the person at the door, without considerations of the other elements. This is also the old-way in aviation safety. There is only one safeguard and that is the pilot. This safeguard is placing unreasonable expectations on one person to be perfect in all tasks, to always be vigilant and to never let person or mind leave the post. The new way of SMS and just culture is to implement support systems for continuous safety improvements for the flying customers and aviation services.  


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