Introductory Remarks by Robert L. Sumwalt, III
National Transportation Safety Board
FAA 3rd Annual International Aviation Safety Forum
November 3, 2006
Good morning. I am pleased to moderate this panel on a subject that I feel is very important – safety culture. I believe we have a very interesting panel this morning of distinguished speakers, including top-ranking regulatory officials, operators and the president and CEO of an up-and-coming aircraft manufacturer.
Not only do our panelist and I feel that developing a safety culture is crucial, but the National Transportation Safety Board also firmly believes that it is essential. After seeing a number of accidents where the safety focus of the organization was cited, in 1997 the NTSB hosted the Symposium on Corporate Culture and Transportation Safety. The symposium was attended by more than 500 participants from all transportation modes.
Then-NTSB chairman Jim Hall told the audience: “We’ve found through 30 years of accident investigation that sometimes the most common link is the attitude of corporate leadership toward safety. The safest carriers have more effectively committed themselves to controlling the risks that may arise from mechanical or organizational failures, environmental conditions and human error.”
The theme of this forum is “Safety from Top to Bottom,” and I have long believed that safety culture is something that has to start at the top of an organization and permeate the entire organization. If the leaders are not on board and truly believe in safety, then how do we expect others in the organization to embrace it?
To get us all on the same page, what is culture? The dictionary defines culture as “a set of established beliefs, values, norms, attitudes and practices of an organization.” Quite simply, it’s the way we do things.
Now, to build on that, what is safety culture? I simply define safety culture as “doing the right thing, even when no one is looking.” This requires integrity of the system and the people working within it, and core values.
Consider these questions: Do people in your organization do the right thing, even when no one is looking? Do you have integrity in your organization? What are the core values of your organization? Do you have a safety culture?
As you think through these questions, if you are not pleased with the answers, don’t lose hope. In fact, I believe our panel this morning will provide you with some provocative thoughts for establishing and improving safety culture. Before I turn it over to our panelists, allow me to briefly discuss a few elements of safety culture, as defined by Professor Jim Reason. Dr. Reason states that safety culture consists of five elements: informed culture, reporting culture, learning culture, just culture and flexible culture.
An informed culture means that the organization collects and analyses “the right kind of data” to keep it informed on the safety health of the organization. It creates a safety information system that collects, analyzes and disseminates information on incidents and near-misses, as well as proactive safety checks.
Reporting culture is when employees are open to report safety problems. They know they will not be punished or ridiculed for reporting. The Flight Safety Foundation Icarus Committee stated several years ago that if you expect employees to provide you with information about safety issues, then you must have a non-reprisal policy signed by the CEO. This policy reassures employees that the organization will not initiate disciplinary proceedings against an employee who discloses in good faith a hazard or safety occurrence that is the result of conduct that is inadvertent, unintentional or not deliberate. Another essential element is that employees know that confidentiality will be maintained or the data are de-identified. Employees must also know that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting of information.
Learning culture essentially means that an organization is able to learn and change from its prior mistakes.
Just culture is essential, but I find that it is often not understood or
appreciated. Just culture means that employees realize they will be treated
fairly. Not all errors and unsafe acts will be punished if the error was
unintentional. However, those who act recklessly or take deliberate and unjustifiable
risks will be punished
The March 2005 Flight Safety Digest was devoted to the notion of just culture. The article defined just culture as, “An atmosphere of trust in which people are encouraged (even rewarded) for providing safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. “
Flexible culture means that the organization has the culture capable of
adapting effectively to changing demands.
Each of these elements just mentioned are like geared wheels that are turning together to propel an organization towards safety culture. If one or more are missing, the gears don’t achieve their intended results.
I will close on this note: A few minutes ago I asked if you
had a safety culture. In reality, I hope that you do. But, Dr. Reason has
some words to keep us on our toes. “Finally, it is worth pointing out that if you are 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… [T]he process is more important than the product.” That
something to think about. We don’t want to ever get so smug and think
that we are “there” because as soon as we do, things have a
way of reaching out and biting you.
It is now my pleasure to introduce our distinguished panelists. I hope you find the panel to be enlightening.