During a multinational naval exercise ‘MALABAR’ way back in 2007, I had the good fortune to be embarked on one of our frontline ships. A young US navy Lieutenant was embarked on this ship as part of the exercise. Our attention was immediately drawn to a small vial strapped onto his uniform belt. Several guesses were made on its contents, including seasickness pills, spy camera and even cyanide capsules! Two sailors from the same USN team embarked on our ship finally removed and put away their capsules, tired of answering repeated queries posed to them below decks about its contents.
I subsequently learnt from the officer that the capsule actually carried a pair of ear protection plugs, with a standby pair as backup!
Most of us from India were surprised and amused, but the officer stated quite matter-of-factly “safety is not an option, it is the course”. Wise words indeed, coming from someone relatively young in service.
Why are we different?
Socio-Cultural Factors. Traditionally, Indians have, by and large, nurtured an indifference to safety. This indifference pervades every aspect of our social and professional lives. Safety in our homes, at the workplace, on the roads or in health care, all suffer from varying degrees of disregard. Even if we were to disregard the scores of lives lost by buses falling into ravines, trains going off the rails, buildings collapsing and people succumbing to illicit drinks, we would still be left with an elaborate list. Sadly, India is one among those countries where frequent catastrophic consequences and death has gained acceptability. This has to change.
Organisational Values. Safety goals need not necessarily coincide with the performance goals in every organization (unless the sole or primary purpose of the system is to maintain safety) and they sometimes do conflict. Moreover, while organizations often verbalize consensus about safety goals, performance and decision making may depart from these public pronouncements. Only a top-down approach works. Safety as a value cannot be promoted by lower echelons because non-safety goals are often best achieved in ways that are not consistent with designing or operating for lowest risk. Unless the emphasis on safety is ingrained into the management and all stakeholders top-down, it cannot be sustained.
Performance versus Safety. An important influencing factor could be an unbalanced emphasis on performance (military) or revenue (commercial operations). When safety goals conflict with other goals, the resolution of conflict may not always result in putting the safety goals first by everyone in the organisation unless there are safeguards to require this. Internal and external pressures can easily cause organizations to focus on operational goals at the expense of safety goals. But like a popular flight safety poster reads ‘If you think safety is expensive, try an accident’.
Blame Culture. No initiative for improving safety standards can be successful without completing the feedback loop. Unfortunately, improvement of an underlying culture often requires additional effort, and the ability to recognize and confront personal limitations and shortcomings. In a culture where public scrutiny of any shortcomings is likely to result in a truncated career, where is the incentive to speak up? Honest involvement and empowerment of all personnel without fear of retribution or penalty is essential to ensure continuous improvement of safety. The ‘blame culture’ does not permit this. Robert Sumwalt, who on 10 Aug 2017 became the Chairman of the US National Transportation Safety Board, said in one of his speeches “the discovery of human error should be considered the starting point of any investigation, not its end point”.
Just Culture. Eurocontrol, an intergovernmental organisation with 41 Member and 2 Comprehensive Agreement States that works to improve air traffic management performance defines ‘Just Culture’ as ‘a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated’. Suffice to say, in India, ‘just culture’ is just on paper. The system goes hammer and tongs at individuals who are found at fault and an atmosphere of fear and mistrust pervades every aspect of aviation, be it operations or maintenance.
Core Values. Core values are constant and remain a part of the organisation’s culture whereas priorities may change. It is interesting to ask ourselves, do we consider safety as a core value, or rather as one among various priorities? If not, amidst numerous and often conflicting priorities competing for attention, safety will invariably get relegated.
Non-Aviation Corporate Sector Safety Culture
The business practices that high-performing corporates use to create a culture of safety within their organisations were evaluated as part of a study under the aegis of the Deputy Assistant Secretary of the Navy for Safety (DASN (Safety)) in the United States in Apr 2003. All the companies that were studied were involved in some form of hazardous activity. We could draw a few lessons from the findings. As per the study, the industry leaders’ approach to managing safety had the following features in common:-
- Safety was defined as a core business value and not relegated to a process, priority or program.
- Safety performance was linked to the corporate bottom line.
- Employee involvement and empowerment in the safety program was promoted.
- Regular evaluation and analyses of worksites was conducted to identify potential hazards.
- A rigorous accident/incident/hazard reporting system was in force.
- Safety results were included as part of their budget development and reporting system.
Do We Want to Change?
The real question facing us is not whether we should change, but rather “Do we want to change?” Change that is not rooted in culture can be ephemeral. Real long-term reversal of culture takes years. People resist changes that undermine their hard won expertise, status, identity, habits, and understandings. Culture cannot easily be mandated – it develops over time as a successful adaptation to conditions, bringing about desired results and defining desired norms and values.
Lead by Example. Leaders must be aware that their actions are being closely watched at all times. The ideal goal is for aircrew and technical/support staff to move from being supervised to being self-supervised and to make the safety-related decisions themselves. A good example of where leadership can make a difference is to create an environment wherein people own up their safety violations without personal ego or fear of losing face.
Hazard Reporting Procedures. Hazard reporting procedures and analyses as well as mishap investigation are central to a viable safety culture. The Operational Hazard Report (OHR) is a powerful tool designed to serve this purpose well. However, while an ‘OHR’ of minor / administrative nature is discussed and given due attention, those of a serious nature may seem to hurt the organization or client. There would inevitably be the temptation to dissect such hazard reporting with the intention of either covering up the tracks or ‘shooting the messenger’. Such recourse, even if not carried through to its entirety, sends a wrong message down and will be self-defeating in the long term. A little reflection would reveal if the number of hazards that we see around us is anywhere near the numbers reported through OHRs. The damage done to the system by neglecting or discouraging honest hazard-reporting is far-reaching and permanent. Many eyes and ears that could be potential sources for hazard reporting will simply dry up. Encourage and reward, rather than frowning upon the messengers.
Technology. Technology alone cannot solve the safety problem, but it can have a positive effect when used to manage safety. Technology can be utilised to mitigate the risk level in all areas of work by using the appropriate safety equipment, enhancing communications and upgrading old and obsolete systems so that people can operate with greater redundancy and better aids.
The power of information technology can be garnered to disseminate safety information across the community. Put safety information database online so that personnel can report mishaps more quickly, easily and with greater transparency. Operators should be able to analyse mishap and hazard data in real time without the veil of secrecy. Scope and depth of air accident investigations, timely issue of preliminary / final reports and dissemination of safety lessons is another area where India needs to evolve.
Operational Risk Management. It is true that the best safety device lies between your ears. But there are tools to help you grapple with peculiar situations, ORM being one of them. Unfortunately, although an effort has been made to train and implement ORM, its application on the field still has not seen the light of day. Most aircrew in India can’t even recall the basic steps to an ORM analysis. ORM is a powerful tool, but we will not realize its potential unless we care to use it. This brings us back to the same question – “Do we really want to change?”
Building Redundancy. One of the daily challenges that operators face is the lack of redundancy in terms of aviation resources, both men and material. When the military commander or a company’s ‘Accountable Manager’ is left to manage with scarce resources without adequate redundancy, situation is ripe for short-cuts and clouded judgement under the incessant operational tempo. Perhaps, we need to ask ourselves from time to time “Have we stretched ourselves too thin?”
Improving safety essentially requires a paradigm shift in culture at all levels. The lacuna in our system today is clearly one of mindset and priorities, more than inadequacy of written safety guidelines. The first steps towards this change must therefore take place in our minds. There can be no master plan without this. In a nutshell, there is a need to move on from attacking the symptoms to addressing the root problem, which is that of culture.
© KP Sanjeev Kumar, 2017. All rights reserved.
This article has been excerpted from a paper I presented at the Indian Navy’s Annual Flight Safety Seminar in 2007 and later published in Naval Aviation Journal ‘Meatball’. Views expressed are personal and written with a view to introspect and encourage positive changes. Feel free to debate and contribute to the discourse. I can be reached at firstname.lastname@example.org.
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