30 May 2024
The Importance of Safety Leadership in Safety Culture
Explore the evolution of aviation from 'Jurassic planes' to advanced fly-by-wire aircraft, witnessing significant changes in safety management and culture.
During my career as a pilot, I had the chance to experience the extraordinary evolution of commercial aviation. The aircrafts I flew ranged from old generation jets we like today to call ‘Jurassic planes’, to the digital age aircraft with fly-by-wire and advanced safety devices.
I witnessed similar changes in the way safety was managed. During the Jurassic period, not long before I started my professional life, safety was seen as a natural result of reliable and well-maintained aircraft, experienced and disciplined pilots, and strict compliance to all regulatory requirements. When not ignored, human errors were considered a regrettable aspect of aviation. The word “risk” was a taboo. Nobody dared to write that flying, loading, and maintaining aircraft create risks that had to be managed. Airlines used to name an experienced captain as a safety advisor to the top management. They were some kind of safety Gurus. CEOs honestly believed that safety was not part of their job. Legal departments occasionally suggested adjustments to the organisational chart to add layers between CEOs and safety issues. At the front line, reporting and safety information sharing was limited, both internally and within the industry.
Such was the culture prevailing at that time. Today, safety is managed without waiting for accidents to occur. Hazards and risks are openly mentioned and addressed. Human errors are recognised, analysed, and anticipated as far as possible. Top managers and CEOs consider safety as part their scope. Most of them understand their contribution to safety and how they could influence it positively or negatively. Safety leadership and safety culture were drastically transformed.
How did this change happen?
There are too many reasons to mention them all. Remarkable people and leading organisations played a key role. Two examples come to mind:
The first one is related to the early role of FDM programs of two pioneer airlines in Europe. Until the mid-60s, flight data recorders were exclusively exploited for accident investigations. The certification of the first autoland systems brought a different perspective. Because recorders were used to monitor the autopilot performance during autoland, it appeared that the nature and the amount of data made available could help to monitor many other aspects of the flights. So, why not use them to learn from daily operations? The confidentiality of data was an issue but people of goodwill, from pilots’ organisations and airline management were deeply convinced that, if properly used, recorded data could contribute efficiently to prevent accidents.
They were able to establish and sign the first FDM agreement, between the pilot association and airline management. A periodic safety bulletin was published, to anonymously share the most significant FDM events. Without being fully aware of it, these visionaries paved the way to modern safety information sharing, just culture and the basics of safety assurance. This was done years before any regulatory requirement thanks to a few people. When I began my professional life, our FDM program was already 10 years old. It was well accepted, and the agreement has never been breached since. This has a deep effect on our airline’s safety culture.
Some years later as a young manager, I was tasked to organise an internal safety seminar. I visited Dr. James Reason at Manchester University. He had kindly agreed to come to Paris and to speak. We worked together on the messages to be delivered. The airline culture was very “compliance-oriented”. We wanted to make it more safety-oriented. “How does an organisation remember to be afraid when it has not had a bad accident in the very recent past?” and “Will the things done yesterday and today continue to protect the airline tomorrow?” were the types of questions we discussed. With his sense of humour and pedagogic talent, James Reason convinced the attendees to “add a zest of paranoia” at each level, referring to Earl Wiener's Philosophy, Policy, Procedure and Practices. He agreed to say that the amount of zest should be kept reasonable. More importantly, he presented and explained his safety model which, once simplified, later became the famous Reason’s “Swiss cheese model”.
How far the managers remembered the zest of paranoia is not clear, but the Swiss cheese model changed the way managers looked at safety. After a bad event, the usual suspects at the front line were less and less considered in isolation. Organisational factors become part of the analysis. We know this metaphor was so powerful, that it spread out within the aviation world and beyond. Here again, this was a question of influence, not compliance.
These two examples demonstrate how safety is also a question of influence, not only regulation and authority. How do we put it into practice?
Some years ago, Delta Airlines and Air France, the two Skyteam Alliance co-founders, were mutually presenting their safety organisation. We were different by our size, aircraft fleets, network, and operational culture but we shared the same vision of our role as safety managers. On one slide somebody wrote: “We (safety managers) do nothing”. These were provocative words, but the meaning was clear for all: our role is to support, inspire and guide to make decisions and actions at all levels as safe as possible, not to act in place of the people. From senior management to front-line actors, this is done by providing them with credible information, without being hierarchical to the people we are talking to. The principles were simple. Putting them into practice was another story. Crying wolf wrongly, or too often and you are not listened to anymore. Being ignorant of management constraints and front-line daily environments, and targets will be missed. This must be finely tuned.
This is where safety leadership and safety culture meet.
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Bertrand de Courville
Safety Management Consultant
Bdecourville@abdcgroup.com
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