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Safety Culture

Using SMS and Managing Errors

Safety Culture

Safety Culture

As part of aviation’s ongoing effort to improve safety, SMS provides a standardized framework to construct a means of organized data collection and analysis of errors, adverse events, and near misses. Its ultimate effectiveness depends upon the willingness of individuals in an organization to report such information. Because of that dependency, it’s important to understand how to cultivate an atmosphere that increases the probability and opportunity for such reporting.


Establish a Positive Culture
Whether positive or negative, an organization’s safety culture is an expression of how safety is perceived, valued and prioritized by management and employees. A positive safety culture establishes an environment of trust and understanding, where all staff members are encouraged to communicate safety-related concerns, observations and events. As stated by ICAO, “when the organization has a positive safety culture, and this is visibly supported by upper- and middle-management, front-line personnel tend to feel a sense of shared responsibilities towards achieving the organization’s safety objectives.”


A positive safety culture relies on a high degree of trust and respect between personnel and management. Time and effort are needed to build a positive safety culture, which can be easily damaged by poor management decisions and actions, or inactions. Continuous effort and reinforcement are needed. When leadership actively endorses safe practices, it becomes the normal way of doing things.


Management must create an environment where employees confidently come forward in the interest of improving safety. Aviation operations must have a reporting policy that properly protects staff from retribution when reporting violations. Leaders must actively promote employee communication and respond consistently and appropriately to reported or discovered errors.

Responding to Errors
In a positive safety culture, errors are evaluated by contributing factors and root causes to determine accountability. It is not a blame-free environment, but one where individual responsibility is measured against behaviors. An accurate diagnosis of the relationship between errors and actions defines the investigative approach of the organization and enhances the reporting activity of the employees.


Behavior that increases risk can be grouped into four categories: human error, negligent conduct, reckless conduct, and intentional violation.


Human error is a mistake that inadvertently leads to an increase in risk. In these cases, it is essential that errors are not hidden but promptly communicated.


Negligent conduct is defined as a failure to exercise the skill, performance, and learning expected of a prudent aviation employee. In this situation, the employee should have been aware their actions increased the probability of an undesirable outcome.


Reckless conduct always involves a conscious disregard of risk, and thus differs from negligent conduct in that it is a conscious, deliberate behavior.


An intentional violation occurs when an employee knowingly violates a rule or regulation while performing a task. This action may have legal or regulatory implications. It’s also important for leaders to understand that not all intentional violations are bad. Even though aviation is a rule-based environment, situations arise that do not fit existing rules and demand improvised responses to complete a task. In these circumstances, rule deviation may be necessary to re-establish an acceptable margin of safety, making the actions justifiable.


In any safety related event these behaviors can overlap, creating confusion for management in determining the appropriate response and action.


Disciplinary Action
Disciplinary actions often mistakenly condemn human error and create hostility among staff. Improving safety depends on the ability to learn from mistakes regardless of whether they caused damage or injury. To promote a culture that learns from errors, organizations must evaluate how their disciplinary and reporting processes align with this objective. Disciplining employees in response to human errors without adequately considering all causes is detrimental to a safety culture.


Management’s approach to the relationship between errors and actions determines the willingness of employees to report mistakes and violations. A positive safety culture perspective places emphasis on learning to reduce mistakes and improve safety. This strategy is effective because most violations are caused by human error, not negligent or willful misconduct. When this reality is acknowledged by the leaders of an operation, backed up by established written policy, and validated by example, employees will respond with increased reporting.


Outcome-based disciplinary action can cause issues when conflicting responses are given for the same behavior. Identical actions may result in different outcomes, some more severe than others. The safety culture should offer staff the opportunity to learn from mistakes and only apply disciplinary action that reinforces acceptable expectations.

Use and Improve the Safety Management System
Risk factors dramatically increase when intentional violations become everyday behaviors. Employees may not be aware that these violations have increased the risk to the operation. If they are discovered as the result of a proactive evaluation, these violations become learning opportunities to improve safety. Use the safety management system to identify specific tasks or employees that are most prone to violations, and thereby increasing risk.


Establish Effective Safety Reporting
Every employee plays a role in the reduction of risk for successful operations. Collectively their actions that contribute to the safety culture. Errors cannot be corrected, and risk can’t be managed without effective hazard reporting.


The safety reporting process must be easy to follow, accessible, and consistently applied in order to reinforce the safety culture. Make sure staff recognize hazards and feel comfortable reporting them. Management must address reported concerns quickly and develop successful corrective actions.


Coordinate Safety Culture and SMS System
Aviation operations need both a positive safety culture and an effective Safety Management System (SMS) to achieve their best safety performance. SMS Systems, like PRISM ARMOR, provide convenient and appropriate safety reporting and risk management tools that help construct a positive safety culture.

Every aviation operation differs, so the approaches to creating a positive safety culture will vary somewhat. Organizational nuance aside, the environment, policies, and characteristics inherent in a positive safety culture are consistent. ARGUS consultants have the experience to help airline operations create and improve their own safety culture.

Written  By:

JR Russell

Executive Vice President, PRISM

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