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Creating a More

Effective Safety Culture

Airlines seeking ways to create safety cultures should clearly distinguish between
acceptable and unacceptable behavior. A good safety culture facilitates the
implementation of a Safety Management System (SMS) through encouraging
collaborative participation in event investigation and the reporting of important
safety-related information.

By Maggie J. Ma, Ph.D., Certified Human Factors Professional, Systems Engineer, Maintenance Human Factors, and
William L. Rankin, Ph.D., Boeing Technical Fellow, Maintenance Human Factors

The Boeing Maintenance Human Factors ESTABLISHING AN SMS Maintenance Error Decision Aid (MEDA)
team provides implementation support to process. (For more information about
customer airlines on a wide array of main­ Most civil aviation authorities around the MEDA, see AERO second-quarter 2007.)
tenance human factors safety processes world either already require or will soon
Proactive. An organization’s activities to
and programs. Operators often ask the require airlines to have an SMS (see Federal
identify safety risks are analyzed based
team how to promote or facilitate a good Aviation Administration [FAA] Order VS
on the belief that system failures can be
safety culture in order to implement these 8000.367A - Aviation Safety (AVS) Safety
minimized by identifying safety risks within
processes and programs. Management System Requirements). An
the system before failure occurs. Examples
This article defines a good safety culture SMS involves using reactive, proactive, and
include quality assurance audits and volun­
in the context of implementing an SMS, predictive hazard identification processes.
tary reporting systems, such as hazard
out­lines the limitations of discipline, pro­vides
Reactive. Accidents and serious incidents reporting systems and the Aviation Safety
practical steps on how to establish an
are investigated based on the belief that Action Program (ASAP).
effective safety culture, and recommends
organizations should learn from their mis­
strategies for dealing with ineffective norms Predictive. This approach/process captures
takes, which provide valuable information.
in the workplace. system performance as it happens in real-
An example of a reactive hazard identifi­
time normal operations, based on the belief
cation process for maintenance is the

Figure 1: Three interrelated aspects of a safety culture

Safety Culture

“The product of individual and group values, attitudes, perceptions, competencies, and
patterns of behavior that can determine the commitment to and the style and proficiency
of an organization’s health and safety management system.”

Psychological Aspects Behavioral Aspects Situational Aspects

How people feel What people do What the organization has

Can be described as the “safety Safety-related actions Policies, procedures, regulation,
climate” of the organization, which is and behaviors. organizational structures, and the
concerned with individual and group management systems.
values, attitudes, and perceptions.

A Three Aspect Approach to Safety Culture (adapted from the U.K. Health and Safety Executive Research Report 367, 2005)

that safety management is best accom­ employees should not be disciplined for ■■ Just Culture. An atmosphere of trust is
plished by aggressively seeking information reporting bad news (e.g., incidents and present and people are encouraged or
from a variety of sources that may predict safety hazards). even rewarded for providing essential
emerging safety risks. Exam­ples of these safety-related information, but there is
sources include main­tenance reliability also a clear line between acceptable
programs, airplane health man­agement and unacceptable behavior.
program, and maintenance line operations
In the 1997 book Managing the Risks of Of these elements, Just Culture is
safety assessment (LOSA). Maintenance
Organizational Accidents, James T. Reason critical and lays the foundation for the other
LOSA is a tool for collecting safety data by
wrote that a good safety culture comprises elements. Just Culture refers to how a
observing maintenance technician behavior
five elements: company deals with the issue of discipline
during normal mainte­nance operations.
and is not equivalent to an absence of
(For more information about LOSA, see ■■ Informed Culture. Those who manage
disciplinary action.
AERO second-quarter 2012.) and operate the system have current
A Just Culture emphasizes shared
An SMS is much more effective when it knowledge about the human, technical,
accountability between the organization
is implemented within an appropriate safety organizational, and environmental fac­
and its employees. In the Just Culture,
culture. The European Aviation Safety tors that determine the safety of the
an individual employee is not held account­
Agency first promoted “Culture of Safety” system as a whole.
able for system failures over which he or
in its basic regulation (EDC 216/2008) that
■■ Reporting Culture. People are willing to she has no control, but it does not tolerate
reporting of incidents and other safety
report errors and near misses. conscious disregard of rules, reckless
occurrences should be facilitated by the
behavior, or gross misconduct. In a Just
establishment of a non-punitive environ­ ■■ Learning Culture. People have the will­ing­
Culture, event investigation looks beyond
ment in order to encourage reporting of ness and competence to draw the right
the “who” and searches for the “why” so
safety information. A U.K. Health and Safety conclusions from their safety information
that system issues that lead to errors and
Executive Research Report reviewed safety system and the will to implement major
violations can be fixed. A Just Culture
culture and safety climate literature and reforms when the need is indicated.
recognizes that a large proportion of unsafe
identified three interrelated aspects of
■■ Flexible Culture. Organizational flexibility acts are honest errors, and there is not
safety culture (see fig. 1). The International
is typically characterized as shifting from much corrective or preventative benefit
Civil Aviation Organization discusses
the conventional hierarchical structure from discipline. According to Reason,
“non‑punitive reporting systems” in its
to a flatter professional structure. only about 10 to 20 percent of actions
SMS train­ing. “Non-punitive” means that

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Developing an effective safety culture
According to Heather Baldwin in the article improved, and consequently safety perfor­ Transparency. Establish a mechanism that
“Remove Your Roadblocks” pub­lished by mance will be improved. allows employees to express their opinions
Aviation Week & Space in 2012, the fol­ without fear. If there is no such mechanism
Commitment. Commitment-based safety
lowing three principles are essential to or it’s impossible to have such a mecha­
is more proactive than compliance-based
fundamentally change a company culture nism, find the root cause. Sometimes there
safety because employees willingly
and make the transition to a more positive is a mechanism estab­lished, but it doesn’t
participate in the former. To encourage
and effective Just Culture: function, such as an unused suggestion
frontline employees (e.g., maintenance
box or managers who collect employee
Integrity. Consistency and predictability technicians) to be more actively involved,
feedback as a formality but don’t actually
help build trust. If employees know that they need to be empowered and given
listen to what employees have to say.
a safety policy/procedure applies to every more control. For example, they can
person in the company, and that it will participate in activities to improve work
be enforced fairly, the consequence of processes. When frontline employees feel
violating this policy/procedure is then that their voices are heard and valued by
100 percent predictable. The compliance management, they will become more
to the safety policy/procedure will be motivated and proactive.

contrib­uting to bad events are due to indi­ For example, a company can specify ■■ The effects of discipline can be temporary
vidual issues (e.g., complacency) while the that “it is unacceptable to purposefully skip and can depend on whether the person
remaining 80 to 90 percent are system an operational check at the end of a main­ who carried out the discipline is present.
issues, such as poor training, inadequate tenance task.” If a technician deliberately People only learn “not to get caught.”
equip­ment and/or hangar facilities, mislead­ chooses to bypass the operational check ■■ Discipline often provides little information.
ing or incorrect maintenance task information, disregarding the consequence, there will be It may tell the person what not to do,
design issues, inadequate task handover some form of discipline. On the other hand, but it doesn’t usually tell the person
process, task interruption, and time pressure. if a technician over-torques a bolt because what he or she should do.
If 80 to 90 per­cent of actions leading to an the torque wrench is out of calibration, then
From a psychological perspective, the
unsafe event are caused by system issues, he or she should not be disciplined. Also,
effect of discipline is much less useful than
then discipline is not warranted in a majority companies should base discipline on the
the effect of reinforcement. Disciplining
of the events. behavior and not on the outcome of an
employees teaches them what not to do
A Just Culture doesn’t completely elim­ event caused by the behavior.
(or not to get caught) but doesn’t teach
inate discipline; instead, it draws a clear
them about expected behaviors. Because
line between acceptable and unacceptable
THE DRAWBACKS OF DISCIPLINE each employee can’t be watched and
behavior while specifying potential discipline
monitored constantly, the ultimate goal
for committing unacceptable behaviors.
According to studies cited by psychologists is to have employees perform good,
In general, a Just Culture should lead to
Carole Wade and Carol Tavris in their 2010 expected behaviors on their own. Discipline
an overall reduction in the use of discipline.
book Psychology, using discipline as a often causes employees to hide problems
Management must also ensure that the
control method for behaviors has a number and mistakes.
discipline is carried out consistently for any
of limitations: For example, one organization formerly
member of the company who commits
gave a monthly “no mistake” bonus that
unacceptable behaviors. These acceptable ■■ Discipline is often administered
constituted an important portion of employ­
and unacceptable behaviors need to be inappropriately.
ees’ monthly income: without this bonus,
made known to all employees through ■■ People are so mad that they may make
their daily living would be affected. As a
a clearly written, easily accessible policy decisions based on emotion instead of
result, all of the maintenance techni­cians
and training. facts. Discipline may be applied in haste
in the company reached an unspoken
without detailed, deliberate fact gathering.
agreement that nobody would disclose
■■ The person being disciplined often
a mistake or problem in mainte­nance oper­
responds with anxiety, fear, or anger.
ations. When a part was damaged during
Key behaviors
A “Key Behaviors Initiative” is part of an 1. When performing critical systems or 5. Confirm the integrity of each adjacent
airline’s overall effort to reduce technician principal structures maintenance, review connection after installation of any line
errors in airplane maintenance. Key behav­ the current maintenance instructions replaceable unit.
iors are specific maintenance behaviors before beginning a task.
6. Complete all required checks and tests.
intended to minimize the frequency and
2. Document all additional disassemblies
impact of maintenance errors that could 7. When closing a panel, conduct a brief
not specified in the task instructions.
affect flight safety and reliability. One visual scan for safety-related errors.
airline’s program included the following 3. Document job status at the end of a
key behaviors: shift or when moving to a new task.

4. Flag all disassemblies that might be

inconspicuous to anyone closing the
work area.

a remove-and-replace task, the technicians than individual factors like complacency. Stage 3. Airlines promoted and implemented
would not report it so they would not be Disciplining technicians without fixing those a Just Culture.
disciplined — losing the “no mistake” system issues would do nothing to reduce
Note that the above stages are not
bonus. They waited for the pilots to discover the likelihood that the same error would
sequen­tial or mutually exclusive. They often
any problems during a revenue flight. occur in the future.
overlap with one another and evolve together.
Stage 2. The FAA had the insight to realize
EVOLVEMENT OF SAFETY CULTURE IN that if they disciplined technicians through
letters of investigation and certificate action, CULTURE
then technicians would not voluntarily report
Since the mid-1990s, aviation safety culture important safety-related information. The
An airline culture that heavily emphasizes
has evolved through three stages for FAA encouraged airlines to establish an
punitive actions is not compatible with
airlines operating in the United States: ASAP (see Advisory Circulars 120-66 and
SMS because discipline deters people
120-66B), a joint program sponsored by
Stage 1. Companies adopted event inves­ti­ from voluntarily reporting safety events and
the FAA, company management, and labor.
gation tools such as MEDA to systematically concerns, makes them less forthcoming
An ASAP encourages employees to report
investigate maintenance-caused events. with information when they participate
safety issues (e.g., incorrectly performed
Previously, airlines tended to blame indi­ in event investigations, and alters their
maintenance, near misses, safety concerns,
vidual technicians for making errors. Airline usual performance to model expected
and hazards) at work. If a report is accepted
management worried that they would lose behavior when they are observed during
by the Event Review Committee (com­
the ability to discipline people if they com­ normal operations.
posed of three members representing
mitted to MEDA investigations. Gradually To establish and maintain a good safety
the FAA, airline management, and labor),
through systematic investigations using culture, management must consider taking
regardless of the size of the event or its
MEDA, airlines began looking into factors the following specific actions:
financial impact, the FAA promises no cer­
that contributed to the technicians’ errors
tificate enforcement action against the ■■ Tell employees what are acceptable
that caused the events. Organizations
technician in exchange for information that behaviors and what are unacceptable
started to realize that in most cases the
otherwise may remain unknown. behaviors. (See “Key behaviors” on
errors were due to system issues rather
this page.)

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■■ Obtain commitment from the employees safety or quality director/manager, is the SUMMARY
that they agree with and will comply accountable manager for safety.
with these key behaviors. About 80 to 90 percent of actions leading
■■ Obtain commitment from management to safety events are caused by system
that they will not tell technicians to break IN THE WORKPLACE
issues. Focus on correcting system issues
any of the key behaviors. instead of blaming individuals. An effective
■■ Ensure that leads and supervisors mon­ safety culture is one that clearly states
Ineffective norms (e.g., “everybody does it”)
itor frontline employees to make sure acceptable and unacceptable behaviors
should be considered a system problem,
they comply with the company’s safety while specifying potential disciplinary actions
not an individual problem. Ineffective norms
policy (i.e., exhibit key behaviors and do for committing unacceptable behaviors.
are the result of unacceptable behaviors
not engage in unacceptable behaviors). It encourages employees to maintain pro­
going uncorrected and, therefore, being
■■ If an employee doesn’t perform key fessional accountability and voluntarily
perceived as condoned.
behaviors or commits unacceptable disclose safety-related information, such
Management also needs to act as a role
behavior, there must be consequences as errors, safety concerns, and hazards. It
model for key acceptable behaviors and
(e.g., coaching or a verbal warning). focuses on understanding and addressing
face the same consequences as frontline
However, a gray area exists between safety issues instead of blaming the techni­
employees if they violate them. Otherwise,
unacceptable behavior and blameless cians who were involved. In this self-reporting
employees will get the erroneous impres­
unsafe acts, where the discipline has to environment, safety concerns (e.g., hazards)
sion that requirements don’t necessarily
be decided on a case-by-case basis. tend to get resolved, which improves morale.
have to be followed. For example, if a com­
Boeing provides implementation support
Ultimately, the active involvement of pany requires every­body to wear safety
to customer airlines on a wide array of main­
executive management is essential for glasses and hearing protection in the
tenance human factors safety processes
establishing and maintaining a good safety hangar, then management needs to wear
and programs.
culture. Major safety improvements are pos­ safety glasses and hearing protection in
For more information, email MHF@
sible only if they are driven down from the the hangar — and monitor and correct
top. (See “Developing an effective safety employees’ use of this personal protective
culture” on page 15.) SMS emphasizes that equipment. It’s also critical to provide safety
the company chief executive officer, not the glasses and ear plugs in the hangar and
line maintenance area so that technicians
have easy access to them.


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