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Minimum System output Maximum
Risk
High
Low
Technology
Training
Regulations
Safety space
Violation space
Exceptional violation space
Incident
Accident
System’s
production
objective(s)
A project supported by AIRBUS and the CAAC
June 2007
Culture
􀀴 Culture binds people together as members of groups
and provides clues as to how to behave in both
normal and unusual situations.
􀀴 Culture influences the values, beliefs and behaviours
that people share with other members of various
social groups.
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Three cultures
National
Organizational
Professional
National
A project supported by AIRBUS and the CAAC
June 2007
Three distinct cultures
􀀴 National culture encompasses the value system of
particular nations.
􀀴 Organizational/corporate culture differentiates the
values and behaviours of particular organizations
(e.g. government vs. private organizations).
􀀴 Professional culture differentiates the values and
behaviours of particular professional groups (e.g.
pilots, air traffic controllers, maintenance engineers,
aerodrome staff, etc.).
􀀴 No human endeavour is culture-free.
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Organizational/corporate culture
􀀴 Sets the boundaries for acceptable behaviour in the
workplace by establishing norms and limits.
􀀴 Provides a frame work for managerial and employee
decision-making
􀂃 “This is how we do things here, and how we talk
about the way we do things here”.
􀀴 Organizational/corporate culture shapes – among
many others – safety reporting procedures and practices
by operational personnel.
A project supported by AIRBUS and the CAAC
June 2007
Safety culture
􀀴 A trendy notion with potential for misperceptions
and misunderstandings
􀂃 A construct, an abstraction
􀂃 It is the consequence of a series of organizational
processes (i.e., an outcome)
􀀴 Safety culture is not an end in itself, but a means to
achieve an essential safety management
prerequisite:
􀂃 Effective safety reporting
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Effective safety reporting – Five basic traits
Information
People are knowledgeable about the human, technical and
organizational factors that determine the safety of the system
as a whole.
Flexibility
People can adapt reporting
when facing unusual
circumstances, shifting from
the established mode to a
direct mode thus allowing
information to quickly reach
the appropriate decisionmaking
level.
Learning
People have the competence
to draw conclusions from
safety information systems
and the will to implement
major reforms.
Willingness
People are willing to
report their errors and
experiences.
Accountability
People are encouraged (and rewarded) for providing essential
safety-related information. However, there is a clear line that
differentiates between acceptable and unacceptable behaviour.
Effective safety
reporting
A project supported by AIRBUS and the CAAC
June 2007
Three options
􀀴 Organizations and the management of information
􀂃 Pathological – Hide the information
􀂃 Bureaucratic – Restrain the information
􀂃 Generative – Value the information
Source: Ron Westrum
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Three possible organizational cultures
Hidden
Shouted
Shirked
Discouraged
Covered up
Crushed
Conflicted
organization
Ignored
Tolerated
Boxed
Allowed
Merciful
Problematic
“Red tape”
organization
Sought
Trained
Shared
Rewarded
Scrutinized
Welcomed
Reliable
organization
Pathological Bureaucratic Generative
Information
Messengers
Responsibilities
Reports
Failures
New ideas
Resulting
organization
Source: Ron Westrum
A project supported by AIRBUS and the CAAC
June 2007
Safety investigation
　
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