Human factors for pilots – Safety culture

Human factors for pilots – Safety culture


MAN: Safety culture has as much definitional
precision as a cloud… – As grasping at smoke. – The only way to create a really good safety
culture is to believe in it. It’s top-down, bottom-up. Everyone has got to own it. – The right people and the right culture
and it starts at the top. – It starts right from the top. – I define safety culture as a culture that
allows the boss to hear bad news. – There is no stupid question in safety. – It needs to be ingrained into
the organisation. – Safety is embedded into our processes
and our procedures. – And you’ve got to actually walk the walk,
not just talk the talk. – And that trickles down all the way through. – We all sort of have each other’s backs. – What we want to do is make people think. – Safety first. – They are more than happy to report. – Communication on a regular basis,
transparency, open-air, being involved. – That healthy sense of unease. – Never kind of rest on your laurels when it
comes to safety. – It’s really about trust.
I can’t emphasise that enough. – There’s no blame involved. – It’s not about blaming people
or apportioning blame. It’s not about that at all. It’s just about continuous improvement, really. – And how can we stop it
from happening again? – To assess the risks, manage the risks,
know that they’re there. – Identifying the risks. – You must, you must deal with risk. – But I think the other thing that’s really
important in a good safety culture is that you
concentrate on why things went right. – Because they go right a lot more
than they go wrong. – And we grow on the positives. – And that’s obviously key
to any safety system. – But it’s important to recognise that those
elements don’t just work in isolation. WEBLEY HIRT:
They link to a very strong just culture. – And what are you going to use to help you
understand that you are on downwind? – Um… (INAUDIBLE)
– Very good. Excellent. – Let’s look at how a healthy
safety culture works within an organisation. Our first stop is CAE Oxford Aviation
Academy at Moorabbin, where they instil the principles of safety culture in their
instructors and students right from the get-go. WEBLEY HIRT: We’re very strong
on building relationships from the start of a person’s entering into the business,
whether they’re a student or an instructor. And the reason for that is we value very much fresh eyes coming into the business. And if we’ve got a strong relationship,
those people are better able to provide us with information quickly
about the safety culture of the business. Sometimes they might recognise
something that is now no longer relevant an SOP, that’s out of date, and that may need
to be changed in order to strengthen safety. – Altitude, a little bit. They’ll probably give us a clearance
for airways around 3,000 feet, so we can set that in. CLARE KELLY: Encouraging your staff,
students, instructors – whoever it might be – encouraging them to be able to come forward and be vulnerable and say, “I made a mistake, I did this.” And be able to do that with
the head of the operations or anybody else, that’s a really key, important part
of the company. – It’s not my achievement, this safety culture. It is the instructors who live it,
who are out there and embracing it. STEPHEN KONG:
When students come forward and they do report something, we make sure that they’re not punished. And also, as an instructor myself,
if I’ve had an incident, I will be the first to report it. ANDREA ROBERTS:
It’s collaboration of everything. The boss needs to be with it and if he supports it,
then you empower the bottom and they will grow with you. RICHARD DE CRESPIGNY:
The safety culture will determine that when the leader is not around, that people think, act and communicate in a way to maximise their survival. And that only makes great sense. – At the Toll & NSW Ambulance
Rescue Helicopter Base, Bankstown, they face some of the most challenging
environments on a day-to-day basis, so a just culture sits at the core of their organisation and it exists
to ensure everyone returns home safely. MATT FOX: First and foremost,
you want to get home every day. Everyone on board wants to get home. So trying to ram home that nothing’s
more important, than for me, the four people I’ve got on board. – The heart of just culture allows
anyone to report a problem or own up to a genuine mistake. The whole organisation must be involved,
beginning with the people at the top. RICK SELLERS: I believe that safety culture
is probably the single biggest driver for safety behaviour of people. And when you’ve got an extremely good
safety culture, you will find even people
who have come into that culture will begin to adapt themselves to those behaviours. Yes, the CEO level, they need to be on board and they need to be supportive, but so do all
those key people at all the multiple levels, all the strata of the organisation,
otherwise there will be a disconnect. MARK DELANY: For all operators, the safety
management system should be the tier one document for their business. Everything should fall out underneath the SMS. So when the challenges come ’round
costs and that, rather than focusing just on margin
when they’re talking with a client, focus on talking about safety and the systems and
bring them in and make them part of the story. ADRIAN PARK:
One of the big things that we do here all the time is – “Hey, you made a mistake.” If there’s nothing malevolent behind that, if there was no deliberate maverick
things going on, it was just part of you being a human being, then by me saying it –
“Hey, you made a mistake” – we own our mistakes, we learn from it,
we ask questions around it, we drive on. To me, that is one of the most powerful things
you can do in a safety culture. TIM FRANKEL:
Our staff, whether it be engineers, pilots, crewmen, all feel very comfortable in reporting every incident, no matter how minor. They all also feel very comfortable putting forward suggestions about how
we might improve what we do. MARK DELANY: You can’t just talk the talk,
you’ve got to walk the walk with a just culture because it can take a long time to create
a true just culture in an organisation. But you can kill it pretty quickly, particularly if management aren’t really focused on it
and supportive of it. MATT FOX: It maintains a high standard. There’s nothing that’s swept under the carpet. You know when you go
into an aircraft that if there was a previous unserviceability, then someone has reported
it and if there was a problem, then I have full confidence in the aircraft I am getting in from a
maintenance as well as a piloting perspective. ADRIAN PARK: The mistakes emerge
and they’re no longer subterranean and you can see them in your reporting system or just someone
coming up and talking to you, then you can actually manage them. MARK DELANY: You must, you must deal
with the risk and if that means stopping doing certain types of operations or limiting
the number of people who you can fly or limiting payloads are increasing pilot
experience requirements, it’s what you must do. Rule number-one for me in aviation management is to manage risk
and making sure you always do. You never walk away from it.
You must deal with risk. Your SMS system sets the foundation of your safety culture. If you nurture it, it is like your garden. You look after it, it will grow well. If you don’t look after it, it will fade away. Safety management system is the core
fundamental process of any aviation system. MELANIE TODD: You might hold a meeting
and say, “Last week we had this event. “It was handled really well,
the return was great. “Let’s talk through how that happened.” And then it starts to come out. The training was there, all the drills just happened like they should have,
it was a clear day, there was no traffic, we could see what was going on so we just
returned and that is why it worked. And the tapping into that and saying,
OK, because that training and those drills are working really well,
we’re going to keep them in place. We are not going to say we don’t need them anymore because we do need them,
that’s why that event ended well. The chronic unease is very important but I think also learning why did we do well
in that area and hanging onto the foundational stuff that
meant that you did well is really crucial. MARK DELANY: Here in the ACE facility, we have brought together
all of the simulation technology to allow us to do far higher fidelity training,
far more rigorous training. I often say the ACE is designed, and the ACE
program is, around a holistic outcome. It is not the sum of parts, it is
the holistic outcome we get, for the crew that goes out
on these helicopters are far better trained, are standardised and are more capable and more current
than we have ever seen before. SIDNEY DEKKER: I think one of the
characteristics of a great safety culture is a culture that understands
why things go right, because they go right a lot more than they go wrong. But what we don’t is investing in our understanding of what actually makes these things go right. What we are seeing – and research is pretty
much clear in showing this – is that stopping things
from going wrong only gets you so far. But what we are increasingly understanding
is that we need to recognise, identify and then enhance the capacities in our people,
in our operation that make things go right. – In the unlikely chance of an emergency, please just listen out to my instructions and I
will inform you on what to do and where to go. – So what does a safety culture
look like in the outback? Wrightsair at William Creek is a great place
for young pilots to rack up commercial hours. But the remoteness creates
some unique dynamics. TREVOR WRIGHT: We are a very,
very quirky little business out here from the point of view that the business
actually is in a remote area and everyone has to live in this area. Our nearest town is 200km away
and it’s quite a drive. Everything around us is on dirt roads and if
it rains out here, apart from the aircraft, it can be a week or two weeks before you can
get back in or out of the place. – Despite the tyranny of distance, a safety culture runs deep in the fabric of
operations at Wrightsair and just as it should,
it starts at the top and filters all the way down. There’s no shame in saying that something is outside of your scope and that’s something I really respect about working here. I mean, everyone is familiar with
the commercial pressures and people pay a lot of money to go on flights
and there’s a lot of pressure to get it done. But when push comes to shove, Trevor and
our whole team are very, very much aware that there is no shame in saying,
“No, let’s just sleep on it “and we’ll have a look at it tomorrow.” – All clear! TREVOR WRIGHT: If we find that there is a
situation where there’s been an issue or a near miss,
that we go back and we pull it to bits and we ask, how did this happen and
how can we stop it from happening again? And everyone gets involved in it,
the whole team. What we want to do is make people think. And that’s what safety is all about – thinking
about what you’re doing before you do it. And if some incident does occur, you take it
away and say, how can we stop
this from happening again? Or how do we stop it from becoming bigger
and turning into a life-threatening situation? – On any given day,
an incident can occur. But the most important thing is how
an organisation deals with it, even if it means the boss may
need to invest in a new windsock. TREVOR WRIGHT: Actually, one of the pilots
come over to us and he said, “Had a bit of trouble today –
I couldn’t see the windsock.” I said, “The windsock is out there,
how can you miss the windsock?” He said, “Well, it’s not there! I had to use the secondary yellow windsock to look at the wind direction
and where we were going to land. I said, “Oh, yeah, let’s go over
and have a look at it.” MATT HARNETTY:
So this morning we had one of our planes coming in and he has noticed that
our primary windsock has gone. So whether they have wobbled themselves
out over time, bit of play in the bolts there
as such windsock moves around. You can see the other ones are still firmly
in there but, yeah, just not those ones. – So where do we go from here? We need to inform everyone that is using
these windsocks they need to check them. It is now up to the next level to make sure they have an outcome with it
and to let that manufacturer know. What we have to do is now ring up the local government authority and make
sure that they have followed up with it because if they haven’t followed up with it,
we may as well have not have told anyone. Even though it’s a very slim possibility that
someone can get hurt, there is a possibility that they will get hurt and if we can stop that
from occurring, we’ve achieved something. GRAHAM EDKINS:
We talk these days about the concept of fatal risk or critical risk. What is going to kill somebody or leave them permanently disabled? What are your key risks around that? Know what they are and put in measures
to protect your system against those risks. – Do a rolling take-off with the goal of getting
the thing motivated, – Alright?
– Alright. – Go all the way round?
– Turn a little bit tight down the middle, a bit smoother. – Seair on the Gold Coast is also
a great place for pilots to build up their skills and professional hours while learning
the benefits of a good safety culture. CEO Peter Gash gives us some insights. PETER GASH: The most important element
of a safe culture and a safe aviation business is the right people and the right culture
and it starts at the top. Going to a 1,200m-long bitumen runway is a whole lot different to going
to a 700m, short dirt strip. They do not go until we believe they are ready
and then you regularly check to see. Because humans are humans
and they will evolve and develop their own ideas about
how to do something. – If you keep it about a ten-degree angle,
a bank turn. – Yep.
– Until you get to about 030. – Giving everyone a real nice look out that site.
– Yeah. KIRK CAMPBELL: It’s all about the
senior guys mentoring the junior guys to help them grow and expand on. You’ve got to invest in safety. You’ve got to invest time in it,
you’ve got to invest aeroplanes in it, you’ve got to invest your crew in sitting down and being proactive with it. We have safety meetings now as part
of our safety management system. We’ll have our regular scheduled meetings. Then if there’s anything else that
will come up, we’ll have an unscheduled safety meeting
and we’ll deal with it as a team. – One of the hard things over Lady Elliot
is a full load with no wind. – Yeah. – They are the things you’ve just got to be
mindful of. PETER GASH: Give your team support,
let them know that you trust them, let them know that
you’re there behind them to support them. You’re not out there in the bush in that
aeroplane on your own – there’s someone there on end of the phone or the end of the
radio to help you if you’ve got a challenge. That’s one of the things I like about
the new 135 is that we’ll be air transport, so everyone will have that standard,
everyone will have that expectation. I didn’t realise the advantage that it
brought to my business until a few years into it when I could see – this is changing our standard, our culture,
our philosophise on how we do things. – It’s not just aircraft operators
with a monopoly on safety. On the other side of the microphone, air traffic control have developed
an alive and active learning culture. So one of the key things we do in our system is that we have an open reporting culture and a very, very good self-reporting of incidents. PETER JAMES: Everybody here will have
had a situation where something has gone wrong, a mistake has been made. Some more serious than others,
but the bottom line is you report it. If it’s required, we investigate what happened and we try and improve from it
and try and learn from it. JOHL BROWN: What’s really important to me
is people feel comfortable enough to report anything that they think there may be an issue with. It is really important that I see
a really good teamwork and that people are working with each other,
that they are happy to challenge each other as well
to improve general safety and efficiency. DAN PHILLIPS:
Every time there is an incident or an occurrence of some sort, it is reported through our Cirrus system and it is followed up through the management and investigated. It is not a blame, it’s what happened, what can we learn from it and how do we
prevent it from happening again? RICHARD DE CRESPIGNY:
So QF32 wasn’t successful because of me or my team, necessarily, or even my airline. It is because of the culture in aviation to share information, accept people make mistakes. That is the human condition. Learn from it, build up the human factors so good people come together
into perfect teams and then we can truly be remarkable.

Author: Kennedi Daugherty

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