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Safety Culture

CHIRP reporting themes

My first six months as Air Transport (AT) and Advanced Air Mobility (AAM) programme manager in CHIRP’s aviation team has been both enlightening and professionally rewarding. Having previously been a member of the Air Transport Advisory Board (ATAB) I was very familiar with how CHIRP’s advisory boards dealt with the human factors based reports presented to them for discussion, but now that I’ve taken on the newly created AT/AAM PM role, I have more insight into the reports as they arrive into CHIRP, and importantly, I’m able to have direct contact with the individuals who report in to us with their concerns. Reporters’ motivations for submitting confidential reports to CHIRP vary greatly, as you’d expect, but a few common themes involving safety culture are appearing from my first six months in the job. I thought I’d share some of these with you having been given this opportunity to write my first editorial for Air Transport FEEDBACK. But before I do, I wanted to set the scene regarding what I believe is meant by the term ‘safety culture’ in aviation, as the concept is very pertinent to the subject of Air Safety Reporting (ASR) in general, and confidential reporting in particular.

Safety, in its broadest sense, represents the priority given by an organisation, at every level of operation, to keep employees and customers free from harm. Culture, as it relates to humans working within socio-technical systems, refers to the prevalent attitudes, behaviours, and beliefs that exist amongst a majority working within the organisation. Culture, in a nutshell, determines what is deemed acceptable behaviour within an organisation. Therefore, when a genuine safety culture is said to exist in an organisation, it will reflect a commitment by senior leadership, and all others in the organisation, to prioritise safety and to continuously learn and make improvements based on events that occur and the personal experiences of employees. The organisation promotes and values those attitudes, behaviours, and beliefs that facilitate safe outcomes, and always above other considerations, such as those associated with short term financial or operational pressures. Positive safety culture includes clearly defined safety responsibilities and accountabilities, effective teamwork to achieve a common set of well understood safety goals, open and honest reporting of hazards and near misses, errors, mistakes, incidents and accidents, and finally, a feeling of trust throughout the organisation that safety really is, yes, let’s go ahead and say it… “the number one priority”. An easily said strap line, and one that is arguably overused, but is in fact a very high bar to reach, particularly in the cut and thrust world of 21st century commercial aviation!

Here at CHIRP we often receive reports that highlight what can happen when an employees personal experience of their organisation’s safety culture is at odds with what is said on the company’s SMS intranet site, or on notice board posters in Flight Ops, and therefore falls short of the ideal. A recent confidential CHIRP report stated that there was a perceived “punitive culture’’ prevalent at an airline and the reason that the reporter felt compelled to write to CHIRP was because they feared retribution and actions against them if they submitted an internal ASR.  Another report into CHIRP stated that the employee had submitted an ASR but had still not received an acknowledgment from the safety team, let alone a detailed reply. Sometimes, CHIRP is told, the reply to an ASR is simply that the report “is now closed’’.  It is worth remembering that an effective safety culture can only exist when all employees feel able to report without fear of a negative outcome.  The concept of Just Culture attempts to capture how this is done, which as James Reason identified, is when an organisation has a “just and fair approach” to errors and mistakes as and when they are identified. But this only works both ways; SMS require employees to submit internal reports to identify hazards and risks, but in return, the leadership must be genuinely willing to hear from employees, even when staff believe management have made errors and mistakes, for example in the interpretation of CAA regulations for Flight Time Limitations and setting rosters that will, based on FRMS reports and ASR reports from employees, result in fatigue.

CHIRP receives reports from individuals who believe that their organisation is playing a sort of game with the regulations, setting schedules and rosters for example that are, by the letter of the regulation, arguably “legal’’ but in the opinion of reporters are not conducive to safe operations when a busy flying roster is considered. Fatiguing rosters, and based on reports received latterly, insufficient or interrupted rest periods, are currently two of the most common reporting subject areas for CHIRP aviation. A worrying aspect that I have noted is that many reporters don’t believe that the safety culture prevalent at their airline encourages them to submit FRMS reports or more generally ASRs about their personal experiences of fatigue. And the very last recourse open to crews, calling in unfit due to fatigue, is viewed by many of the reports we receive at CHIRP as a punishable event in reality. This type of personal experience will determine how the reporters perceive overall safety culture in the organisation, something that is hard to change in a short space of time. CHIRP will always speak up for reporters who feel unable to submit ASRs, backed up with our ability to engage directly with the airlines themselves, but at all times ensuring the confidentiality of the reporter is preserved.

William Dean, Air Transport (AT) & Airborne Air Mobility (AAM) Programme Manager

For all CHIRP Aviation Team, see CHIRP bios.

 

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