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The human operator, the least reliable element of an aerodyne, but the most essential...!
Frank Caron (1991)


Last update:
26 September 2016

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Air Safety - Why air safety improvement is too slow (culture)?

Introduction
After focusing on the people and their relations with the safety system organisation, let's put the light on several cultural aspects as this plays a huge role in the organisation and implementation of the safety concept(s).

The following is not related to a specific culture, a country even a company. It is just a list of issues that inherently result from cultural facets.



A culture of superiority
A lot of organisations think they are the best doing much better than the close or far competitors in every aspect.

Definitely not a very good state of mind to deal about safety especially on the long term...

Recommendation:
1) always adopt an open mind...
2) always consider processes and operations can be improved.



A culture of the presumed
Because personnel are supposed to be aviation professional, there are a lot of presumed assumptions as:

Therefore, a lot of energy, time and money are wasted because personnel questionings, errors, inappropriate decisions and finally a low level operational result.

Recommendation:
set the organisation to the international standards.


A culture of reactivity only
This point concerns the organisation and its links with the safety and the quality. Companies have a certain dynamic as it reacts to situations that arise. These reactions lead to an immediate solution, but ignoring the lessons that may be learned in the future. This generates:

Recommendation:
change for a culture of proactivity and anticipation.



A culture of top-down
This is a huge obstacle to improvements... The following are self-explanatory:

As a consequence the relationships between people are highly childish, as employee just wait the order from above. Even though there may be a better way to perform the task, nobody will dare to raise the concern.

This is emphasized by the importance of the seniority. The older you are, the more ascendance you have on junior (even with few months difference only). It does not matter you are (or not) qualified, the age play the main role.

We all have to learn from everybody…

Recommendation:
1) promote the challenge between every hierarchical level,
2) management level should accept being (positively) criticized,
3) managers must be the first to accept opposite point of views even contradictions.



A culture of cheap…
The main immediate objective is profit. In order to increase this profit, the costs are cut in every possible ways, and the products and or services chosen are the cheapest.

One very big consequence is the important staff turnover beyond a level of normality.

This is more true for the safety which is seen a heavy costly system that does not bring any immediate advantage...

The training is the area that suffers the most from this culture of cheap.

Recommendation:
change for a culture of investment.



A punitive culture vs a just a culture
A just culture use to mean a non punitive environment. In some countries, punishment is a very deep cultural implanted and unmovable concept. And a punitive system get along with a just culture concept. But all punitive cultures are simply a failure.

The reason is that a punishment is a legal concept. If you want to punish people for their bad behavior, you have to provide the list(s) of definitions regarding the non-acceptable behavior. If some are obvious, in many cases it is not as clear as it should be...

Without these lists, the questions remains who will decide there was an error? A manager, a disciplinary officer, even if it is a board, it is very difficult to provide an objective and fair analysis.

Beyond this impossible definition is a huge denial that error belongs to the basic human behavior, a logical consequences of our daily decisions and actions... In the aviation industry, it is said a single pilot makes between 6 and 10 errors per hour... So far, every industry concerned by this issue has not yet found the way to get rid of these behavioral "anomalies", which is just a dream up to now.

In order to change towards different standards, numerous organisations moved to another, but similarly limited, concept: the just culture. If it sounds more fair (just), the problem has only been shifted from acceptable to just. and the question remains: What is just, and what is not?

All the documents I have read regarding this supposed just culture does not mention even a slight definition. It is said something like "the concerned manager(s) will assess the mistake in order to tend toward a just approach" but no clear list about what the operator has to do to fall in the "just" category...

Without a clear description of what can be done and what cannot, there is no way an operator can adjust his behavior.

Finally, a punishment has almost no chance to prevent the mistake to happen again, which is the sole goal of errors management...

Therefore, the only solution is to bring new inputs through education and trainings (read Why training is the main solution to human factors issues), and not only to the concerned employee(s) but to ALL those personnel that may have the risk to do the same mistake.

Recommendation:
1) accept the errors as a byproduct of a normal behavior
2) instead of punishing, provide education and trainings.


A culture of primary objectives only
For an airline, the primary objective is to carry passengers and cargo. How to do it efficiently is not really the question.
Definitely not a culture orientated of details and quality.

Recommendation:
1) develop a real quality program,
2) train staff members to perform quality and focus on details.


A culture of overloading
Personnel are often overloaded with different jobs, sometimes with different positions, regardless their real background.

There is no positive result in overloading people with multiple tasks, but only numerous negative operational consequences as:

  • Struggling to do the daily job(s)
  • Losing the sense of priority
  • Decreasing level of work quality
  • Decreasing the level of expectation, working with minimum objectives
  • Making impossible choices, meaning sacrificing part of the tasks (usually daily tasks)
  • Being in a permanent state of hurry
  • Experiencing stress indeed burn-out
  • And the worse: being demotivated

Recommendations:
1) control the number of assignments to every personnel
2) set clear priorities about the assignments
3) hire qualified people…



A culture of disruption
There is no discipline. It does not matter you are involved with someone or a system during operational duties, people interrupt, without warning. There is no discipline, no consideration about the mistake(s) that can result, people cannot wait.

That may happen even in very critical situations like in an airliner cockpit (the air traffic communications are so far the best daily example). But it happens everywhere in very important meeting, even in hospital during medical examination...

It is definitely a cultural issue in asia but also a lack of education and training.

Recommendation:
train people to have discipline dealing as a group member,
before interrupting.



A culture of captains only
In some airlines, the First Officer are banned to perform some operations (like rejected take-off, cross wind take-off and landing, certain weather operations and certain destination airports, etc.).

Some companies do not provide policies, guidance or directions regarding special situations, like typhoons, ash clouds and marginal weather (or when some notices are issued, they are late, incomplete or operationally not precise enough). Sometimes the Company Manual emphasise these grey areas since they do not clearly mention the conditions to start and continue approaches. As consequences, there are no consistencies in the daily operations since some pilots would consider a GO when other will assume a NO-GO...!

Thus, the captains do not only have the entire legal responsibility of the aircraft but they are also the sole on board trained for these special operations. Even though most of captains are (usually - but not always true) more experienced than First Officers, the commanders are lacking important support in what may be critical situations.

For the aircrafts that are supposed to be certified for 2 pilots, these bans reduce the level of safety since one operator is fully passive because he is lacking some essential training.

The final result is Captains have tremendous weight on their shoulder since they also have to respond to the company weaknesses, deficiencies and loopholes.

Recommendation:
1) train all crew dedicated to similar job with the same training program,
2) provide policies, guidances or directions to deal with critical situations.



A culture of limits
For profit, personnel, aircrafts, operations and system are pushed to the limits.

Departments are often understaffed. Personnel are used at the maximum of the duty time, the flight crew at flight duty time limit and sometime well beyond the (national) regulations. The rest period is not really managed by scheduling department. One of the most important consequences is the constant level of fatigue affecting most of the flight or ground crew personnel.

In some non-English language countries, the common operational language may be very weak. Sometimes operators are not able to sustain even a basic English level for daily operations.

Training for operational personnel is reduced to its required minimal (national) legal requirements. The contents are basics, weak and not adapted to the needs. The updates are often omitted to avoid disruptions in the daily operations.

For ground crew, the standard is very low increasing the work on captains which have to do and check part of the ground staff jobs. The maintenance personnel put a lot of pressure on flight crew to accepts defect(s).

For pilots, recurrent trainings are omitted and the competencies checks are reduced to the minimum removing another chance to get practices and trainings.
Aircraft captains are often the only one to receive certain type of training increasing the burden on their sole shoulder for critical situations.

The result is a level of operations beyond the frame of the basic safety standards increasing considerably every possible sort of risks.

Recommendation:
1) setting up the organisation in every department is a must,
2) safety must not be seen as a cost, buts as an investment for the future.


A culture of required only
It is a very common philosophy, even in western countries. Here, safety is set only because it is a legal requirement from the local aviation authority. Since these authorities usually set only very minimum standards, the organisations stick on these minimum expressing no interest to enhance a complex concept that definitely need an expanded approach.

In other cases, insurance companies can also impose different requirements because the too numerous mishaps experienced by a company. Even though the too numerous mishaps suppose the safety is already weak, these requirements are applied at their minimum, expressing again the same level of indifference to the operational safety needs.

Recommendation:
set the safety well beyond the required minimums.


A culture of painting
This issue is usually linked to the previous one...

Incidents, accidents reporting does not received the treatment required by standards and do not produce a single feedback. The shame to express (internally or externally) any sort of mishaps prevents any improvements.

In such a culture, the safety role is mainly to paint for hiding the areas of weaknesses and deficiencies.

Recommendation:
develop a culture of transparency.



Frank Caron
, December 2010.


quick links

5 steps to convince about safety

Why air safety improvement is too slow (organisation)?

Why air safety improvement is too slow (culture)?

Why training is the main solution to human factors issues

Human factors still the current challenge of the industry

No limits for the understanding of human factors

Suggestions for a discipline committee

Too long briefings

Current CRM have reach its limits

Aviation safety international legal definitions

Two statements about fatigue every manager must know