“Developing a Safety Culture: The Role of Leadership"
Thank you for this wonderful opportunity to be with you! It was two years today that I loaded up my car in South Carolina and drove to Washington to be sworn in as an NTSB Board Member. And what an honor it is to be on the NTSB! I think that, like you, I have had a passion to want to give something back to our profession, and to take our profession and leave it just a little better than when we found it. Do we all feel that passion?
I really do believe that we share that passion. I believe the things you are talking about in this leadership summit are truly things that aren’t going to take the air traffic organization and make it just a little bit better. No, I think the things discussed here are going to help the ATO become a lot better. I don’t say that as an indictment of the current system but I truly believe the things you are talking about this week are monumental in having the ability to take the air traffic organization into a new generation.
I want to talk to you about the leadership role in developing a safety culture. What is leadership? I think leadership means something different to many of us. You can go to a bookstore and there will be scores and scores of best selling books on leadership. But a definition that I resonate to is one by best selling author John Maxwell. He says, “Leadership is about influence, nothing more nothing less.” And when you think about it, that’s what leadership is all about. It’s about influencing others to do, or say, or think, the way that you want them to.
As it relates to safety, I’m going to suggest that as the leaders of the air traffic organization, you not only have the ability to influence safety, but I think you have the obligation to do, so as well.
So let’s talk about some things. I’ll start by asking, Do you have a safety culture? Do you have a safety culture within your facility? Within your department? Within the air traffic organization? Do you have a safety culture? And I certainly hope that you do. But if you think you do, that’s great, but to wake us up a little, I turn to the words of Dr. James Reason: “it’s worth pointing out that if you’re convinced that your organization has a good safety culture, you are almost certainly mistaken…a safety culture is something that is striven for but rarely attained…It is the process that is more important than the product.”
I think that what Jim Reason is saying here is that we certainly hope that you have a safety culture, but we never want to get too comfortable in thinking that. We never want to get smug because as soon as we do we start to relax, we get complacent, and something bites us. So instead of thinking we are there, let’s look at safety and safety culture as a journey - as something that we are constantly striving for. It is that chronic unease that keeps us on our toes. Safety, like safety culture is not discreet - it is not either “off” or “on.” It is a continuum; it is something we should be consistently working toward.
There is presentation tomorrow about safety culture beginning at the top, and indeed I believe that. Safety culture starts at the top of an organization and permeates throughout. It is triggered at the top and measured at the bottom. And what I mean by that is that safety culture must start at the top, it must start with you and it must permeate throughout. It has to include your middle management. It has to include your frontline operators.
If you are out there saying “safety is important,” and people throughout your organization don’t believe it, do you have a safety culture? The answer of course, is no. And another thing we will talk about in a few minutes is that if you at the top are just standing there and giving lip-service to safety, the people in your organization will know that.
You know you are on the right track to establishing safety culture when your employees are doing the right things, even when no one is watching. Are your employees doing the right things even when no one is watching?
A few years ago, I left the beautiful view from an airline cockpit and traded it for a desk, running a Fortune 500 flight department. When I got to this flight department, I have to admit that it was not quite what I had expected. It was in desperate need of some tender loving care and in desperate need of a safety culture. I had been teaching at the University of Southern California, where I lecture on safety culture. I knew I had the academic solution for developing a safety culture, but now I had to apply it to the real world. What we will talk about now are the tools that we used in helping that organization turn itself around and build a safety culture.
I came up with these four milestones through an amalgamation of ideas. I’ve studied the DuPont Corporation to see how they do things; I’ve studies the work of Dr. Jim Reason. I looked very carefully at a study by Lester Lautman and Peter Gallimore from Boeing. So, if you are looking to improve the safety culture in your organization, I guarantee these tools have worked for me and they may work for you. I know they work because today, the flight department that I had the privilege of running, has achieved the International Standard for Business Aircraft Operations (SA-BAO). It is like an ISO 9000 standard. There are only 115 companies in the world who have achieved this standard. The tools we are about to discuss are the tools we used and I believe they can work for you, too.
Management Commitment and Emphasis on Safety
Management must be committed to safety. It is a commitment; it’s the way you do things. Remember, safety begins at the top and permeates throughout the organization. I tried to look for accidents involving ATC to illustrate each of these four points that we are going to discuss. But when it came to this first one, there were so many accidents that involved management commitment or the lack thereof. One thing that we have found at the Safety Board is that across all modes of transportation, through decades of accident investigation, often times the most common link is the attitude of the corporate leadership towards safety. We have found that the more effective organizations have committed themselves to controlling the risks that may arise from mechanical or organizational failures, environmental conditions, and human error. We see that so often. So if you’re looking to improve your culture in your organization, this would be a great place to start. It’s that management commitment.
Standardization and Discipline
Another thing in the roadmap for developing safety is that you must have standardization and discipline. Management has to provide well thought-out procedures and policies and they must stress the need for compliance with these standard operating procedures. The airline where I was employed had five fatal accidents and seven hull losses in five years. The first of these accidents happened just six weeks the airlines consummated a merger. But there was another merger with this company just two years prior to that merger, so we had three large companies being forced together in a two year time period.
After the last of these accidents in 1994, the company realized that they may have taken their eyes off of standards. Any time you take your eyes off of something and look somewhere else, you must refocus. And that is what management decided - we had to refocus on standardization and make sure that everyone flying our airplanes was standardized. And they basically said that from that point forward, there is such no way like a Piedmont way or a PSA way or the way you want to do it. From now on, we are all going to do it the same way and if we don’t, you are not going to fly for us. They insisted on it from that point forward. So when I went to run a corporate flight department, I took this to heart. When I got there, we didn’t have a flight operations manual. We developed one and insisted that we follow those procedures. And I believed in following our procedures so much that I put my money where my mouth was. I tied the department’s incentives bonus goal to the fact that we would all would pass a standardization check ride once a year. And if one of us didn’t pass, none of us got our incentive bonus. I put my money where my mouth was. So believe it or not, people got standardized real quickly.
The point is, it is your job as the leaders to provide well thought-out procedures. It is your job as the leaders to make sure people follow them. I talked with our air traffic control specialist before coming today to ask them to give me an example of an accident or incident that has occurred because controllers weren’t following standardized procedures. And what do you think they said? They said, “We have lots of them.” And by the way, its not just controllers who don’t follow procedures - it is also pilots, mechanics, and others, too. But yes, controller failure to follow established procedures - we have seen that many times. But we have also seen cases of management not providing the proper procedures. I am using this example because it is one that we are all familiar with – the USAir / SkyWest runway collision in Los Angeles. I picked up that accident report over the weekend and I re-read it. The foremost part of that probable cause statement said the NTSB determines the probable cause of this accident to be “the failure of the Los Angeles air traffic control facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operations standards.” It further stated that this failure led to the controller’s failure to do her job properly. Again, I don’t say this as an indictment. I use it as an example to illustrate the importance of people following procedures, and the fact that it is important for leaders to provide proper procedures in the first place.
Training is another milestone in the roadmap to building a safety culture. You must have a strong training commitment to ensure your employees are provided with the right tools to do their jobs. Last October we completed an accident investigation involving an Unmanned Aerial Systems (UAS). This UAS didn’t work the way it was suppose to - it had a lost link and didn’t follow its lost link profile and crashed. But for three hours the controller didn’t know where this UAS was. The Safety Board noted in the accident report that the air traffic organization had not provided the right training for that controller to know what to expect under these circumstances. Again, I am not trying to rub sand in your face - I am merely illustrating that if you expect people to do a job, they must have the right training.
Data Collection and Quality Assurance Programs
And finally, we must have data collection and quality assurance programs. We need data-driven risk management. A few weeks ago I heard Nick Sabatini say that “data is the lifeblood of a safety management system.” I agree. You have to have data to find out where your hazards are, then assess those hazards to figure out what the risks are. Is it an acceptable level of risk?
We need safety audits, both internal and external. We need confidential incident reporting systems. Using the Los Angeles accident again as an example, the Safety Board determined that contributing to the cause of the accident was the failure of the FAA to provide effective quality assurance of the ATC system.
Now, why do we need data? Data, in itself, doesn’t help – we have to translate that data into something useful. Look at it this way: Data creates information, information creates knowledge, with knowledge we can manage risks, and when we manage risks, we are taking action, taking informed action.
Dr. James Reason, says you need an “informed culture,” meaning that the organization collects and analyzes “the right kind of data” to keep informed of the safety health of the organization. You must collect, analyze and disseminate information about incidents and near misses, as well as proactive safety checks. It’s not good enough to just collect it - you have analyze it and disseminate information. When you find something, you have to feed it back to the system so that everyone involved can learn from it. You don’t want to hide this information.
How do you keep the finger on the pulse of your operations? Are you taking proactive measures? Do you have multiple levels of data? I flew airplanes for about 33 years, 24 of them as an airline pilot. To be honest, the engines on my airplane were very important to my family. We wanted to make sure those engines where in good health. We didn’t have just one gage in the cockpit that said engines – “good” or “bad.” We didn’t have that at all. You see those engines were very important so we had multiple indications of the health of those engines. We had N1, N2, EGT, EPR, fuel flow, fuel temperature, oil quantity, oil pressure, oil temperature, and vibration. We had multiple sources of information because those engines were very important to us and we wanted to monitor their health.
In your organization, do you have multiple sources of information? I’m going to suggest that you do. You have sensors in your organization that are like those sensors located strategically on a jet engine that can signal the health of that engine. Your sensors are located throughout your organization – they are your employees.
In order for employees to provide you with information, you must put in place a “reporting culture,” so they are comfortable reporting. Are your employees comfortable coming to you and telling you what you need to know? Employees are open to report safety problems, and in fact, they want to report them. We experienced this at USAir after the last of our fatal accidents. We put in place a confidential incident reporting system in December of 1994. The people who helped us set up the program were amazed at how many reports we had. We found that our employees were wanting to report to us information. All we had to do was ask and put in place the system that would encourage them to report.
Employees generally will report problems when you provide assurances that the information they provide will be acted upon. Face it, we are all busy and no one wants to spend time filling out a form or going to talk to somebody if we don’t feel the information will be acted upon. Employees need to know that the information will be kept confidential, or it will be de-identified. No one wants to come in and say “I have screwed this up. I really messed up and this is why,” and then read about it next week in the company newsletter with their name there. And people have to be assured that they won’t be punished or ridiculed for reporting. Right after the airline put in place this notion that we all must report safety problems, and if we didn’t, we could be subjected to discipline, up to and including termination, if we didn’t report things. So there was something that was really bothering me so I walked into my chief pilot’s office and informed him of my concern. He looked at me and said, “Do you know what your problem is?” I was thinking I really didn’t know I had a problem. He continued, “Your problem is that you are thinking too much. No one else has come into my office and mentioned this problem.” Well, you can be assured the next time I had a safety concern I didn’t go to that person. So you can’t ridicule people; you have to thank them for coming to you. And what is this all about - we want information so we can learn where our system needs correction, so we can improve it and make it safer.
We need a non-reprisal policy. We had this at the airline and I took that idea to my corporate flight department. Basically, it is nothing fancy and it might be three or four or five paragraphs. It is signed by the CEO and the manager of the agency, the facility or department manager. It basically says that it is very important that we have employees reporting their safety concerns. What is said in the third paragraph is very important: we will not use this reporting system to initiate disciplinary action against an employee who discloses, in good faith, a hazard or occurrence involving safety which is the result of conduct that is inadvertent, unintentional, or not deliberate. And that is the key. If someone comes in and says, “I screwed up and this is why,” and they weren’t trying to do it, and it was in fact inadvertent, unintentional, or not deliberate, do you want to punish this person? , Or, would you rather want to learn from what they are telling you so that you can find out where your problems are and correct them.
If you walk out of here with nothing else, this is what I want you to remember: a punitive culture is a poisonous one. A safety culture and a punitive culture cannot coexist. They are dichotomous.
At least two of the presentations tomorrow will discuss “just culture.” What is it? First of all, the word “just” is the root word of “justice” which, of course, means fairness. It basically means that employees realize that they will be treated fairly. There is a tolerance for errors and mistakes. Not all errors or unsafe acts will be punished if the error was unintentional.
Suppose you have a well-trained, well-motivated employee who has a bad outcome on the job. They self report, telling you what happened and why, and how the situation can be prevented from happening again. Maybe they were trying to work around a procedure that doesn’t work very well. Maybe everyone works around that same procedure but this person happened to get caught by the consequences. If he or she comes to you and says this is what happened, do you want to punish this people? That will probably be your best employee because he or she will never make that mistake again. You have the opportunity to learn from it globally and implement improvements to your system. But, if you have a punitive culture, they will not self-report and you will likely not have the opportunity to learn from their mistakes.
Now I want to emphasize that a just culture is not a “get out of jail free” card, nor is it a “no-blame culture. If someone acts recklessly or they take deliberate or unjustifiable risk, are you going to let them out? No. You have to draw a line. Honest mistakes in one category, but on the other side of the line are these deliberate, reckless actions and willful violations. You cannot tolerate those. If you have 95 percent of your employee group trying to do the right things but 5 percent are trying to get around the system and do the wrong things, you can’t just ignore their actions.
With a just culture, you have discipline and you have accountability. Jim Reason describes a just culture as “an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety information, but there is also a line that has to be drawn that distinguished between acceptable and unacceptable behavior.”
So I started this presentation with this question: Do you have a safety culture? And yes, I sure hope that you do. But if you don’t, like Jim Reason cautioned, don’t get smug, don’t get complacent, because as soon as we do, something will bite us.
But if your not satisfied with the culture within your organization, that is okay too, because that is why we are here. We are here to learn and to walk out of this leadership summit reinvigorated about how to make improvements. There is great information that will be presented over the next few days that will help you to develop a safety culture. Hopefully the things that I just mentioned to you, these tools, these four things that have helped me implement a safety culture, can help you.
I look at the safety programs we are trying to put in place as if we are trying and build a wall to protect our organization from bad things. We take all of these programs and stack them on each other and we get a solid wall. Things like policies, procedures, training, the ATSAP program that is getting rolled out, quality assurance, audits, employee feedback, etc. These are all programs, that when combined, help us to build a pretty solid wall to keep bad things from happening in our organizations. But if you notice from the PowerPoint slide, all of these programs do not fit together neatly and we end up with gaps and holes in our barrier wall. With enough force, something could knock down that barrier wall. So, if you are trying to build, how can you make it stronger? You could fill-in the cracks, couldn’t you? You’d put concrete or mortar in there to solidify the wall to make it stronger. That is what a safety culture can do for you. It will fill in the cracks. Your wall will be stronger and nothing will falls through the cracks, because there are no cracks. That is what safety culture can do for you.
I mentioned earlier that if you as the leaders are just providing lip-service to safety, I assure you that your employees will know. How do employees know if leaders are just providing lip-service to safety? The way I describe it is when I was a young boy, I rode horses. I will never forget the first time I was about to get on that horse. I was standing there next to this animal, and I swear, he must have been as tall as this room. I turned to my mom and told her I was afraid. She reassured me and told me not to be afraid because the horse will know if you are scared. “How does the horse know that I’m afraid,” I asked? She replied: “Because they watch you. They watch your actions. They watch the way they do things. They watch your behavior. That is how they know.” So how do your employees know if you’re just providing lip-service? The same way: It’s because they watch you. They watch your actions. They watch the way they do things. They watch your behavior. They watch what you do. That’s how they know.
Remember – leadership is about influence. You can either influence towards safety culture or you can influence away from it. Which do you want? Which is best for the Air Traffic Organization? Which will it be.
I really want to thank you for the opportunity to come and speak to the leaders of the Air Traffic Organization. I think you are on the right track. I applaud your efforts and I hope some of the things we talked about today will help you. Thank you so much for your attention.