Advisory Committee for Natural Resources and …...4 pillars of “safety culture” Culture of...

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Copyright © 2013 JAPAN AIRLINES. All rights reserved. 1 JAL Group’s Approach to Safety - Fostering a Safety Culture - October 7, 2013 Nobuyoshi Gondo Corporate Safety & Security Division, Japan Airlines Document 4, The 4th Meeting, Working Group on Voluntary Efforts and Continuous Improvement of Nuclear Safety, Advisory Committee for Natural Resources and Energy Provisional Translation

Transcript of Advisory Committee for Natural Resources and …...4 pillars of “safety culture” Culture of...

Page 1: Advisory Committee for Natural Resources and …...4 pillars of “safety culture” Culture of decision-making by yourself and taking on challenges Culture of maintaining communication

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JAL Group’s Approach to

Safety

- Fostering a Safety Culture -October 7, 2013

Nobuyoshi Gondo

Corporate Safety & Security Division, Japan Airlines

Document 4, The 4th Meeting,

Working Group on Voluntary Efforts and Continuous Improvement of Nuclear Safety,

Advisory Committee for Natural Resources and Energy

Provisional Translation

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Safety Management in the Aviation Industry

Safety Management Structure of the JAL Group

Safety Management System

Fostering a Safety Culture

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Safety Management in the Aviation Industry

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Hull loss accidents rate in the world is below 1 out of 1 million flights

Source:

World Aviation Accident Rate

Worldwide Commercial Jet Fleet - 1959 Through 2012

総事故率

全損事故率

死亡事故率

搭乗者死者数Onboard fatalities

All accident rate

Fatal accident rate

Hull loss accident rate

年間事故率100万出発回

あたりの

事故件数

暦年

Year

年間

搭乗者

死者数

There is no absolute safety as long as aircraft is operated

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Skill improvement through training

Technological advance

Human factor study

・Safety management ・Establishment of a safety culture

Measures to Reduce the Accident Rate

Times

Accident rate

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Safety means a state in which the risk of harm to people or damage to properties is reduced to the acceptable level and maintained below the acceptance level through identification of the risk factors and continuous risk management.

ICAO’s International StandardsInternational Civil Aviation Organization

国際民間航空機関ICAO

Its member countries shall establish domestic standards in line with regulations, standards, etc. stipulated by ICAO in principle. The Annex to the Chicago Convention (Convention on International Civil Aviation) (ICAO ANNEX) requires individual airlines, control organizations, and airport administrators to implement safety management measures approved by their national governments.

SMS(Safety Management System)

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Trends in JapanIn June 2005, a “Committee for Study of Measures to Prevent Public Transport Accidents Caused by Human Errors,” consisting of the vice minister, concerned bureau chiefs, academic experts, etc., was inaugurated.As a result of studies at the committee, a “Law for Revising Part of the Railway Business Act, etc. in Order to Improve Transport Safety (Comprehensive Law for Transport Safety),” which mandates formulation/notification of a safety management rule, appointment/notification of a safety supervisor, disclosure of information on transport safety, etc., was established, and enforced in October 2006.

Safety Management in JapanSafety Management in Japan

JAL Group’s Safety Management

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Safety policy and objectives

business promises and duties

Safety responsibility

Safety supervisor’s nomination

Adjustment of the emergency plan

Documentation of the safety management system

Management of the safety risk

Identification of the hazards

Risk evaluation and reduction

Safety assurance

Monitoring and measurement of safety performance

Management of modifications

Continuous improvement of the safety management

systemPromotion of safety

Training and education

Communication on safety

Safety Management System Framework

・It starts with defining rules

・Risk management alone is not enough

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Safety SupervisorSafety Supervisor

A safety supervisor is a person who holds an administrative position participating in important decision making on business operation, or in other words, holds an administrative position allowed to become directly involved in important business judgment related to safety such decisions on safety measures and safety investments, and is allowed to directly express his/her opinions at the highest management decision-making bodies such as a the board of directors.

(General guidelines for establishment of a safety management structure, a circular notice by the Director-General, Civil Aviation Bureau)

Managements must properly perceive safety risk

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Safety Management Structure of the JAL Group

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Dec. 2004 Erroneous use of a main landing gear part of a freighter

Jan. 2005 Violation of a control instruction at the Chitose Airport

Mar. 2005 Misunderstanding of a control instruction at the Incheon International Airport

Mar. 2005 Failure to change the door mode of emergency escape doors

Problems resulting from human errors occurred in succession.

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A very serious situation for a company

On Mach 17, 2005, we received the following from the Minister of Land, Infrastructure and Transportation: an “order to improve operations” and a warning letter

An Order to Improve Operations

Article 112 of the Civil Aeronautics Act

Seriousness with only two precedents

The Minister of Land, Infrastructure, Transport and Tourism may, when he/she finds that the business of any domestic air carrier adversely affects transportation safety, convenience to users, and other public interests, …

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Efforts of the management were insufficient to emphasize and spread the fact that top priority should be given to safety under any environment to the whole Group.

Through our work on the improvement of punctuality, recognition when improving punctuality that safety should be the by far the main focus tended to lessen, creating an atmosphere favorable to the coexistence of safety and punctuality.

In the framework consisting of a holding company and two business companies, created in the process of business integration, the management and field workers were not working in close enough contact, and communication among divisions was lacking.

Bidirectional communication from top management to field workers, who directly support safety, was inadequate.

Self-analysis of JAL

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Content of Our Response

Improvement measures in response to the order to improve operations1. Strengthening of the safety management structure2. Company-wide efforts to improve safety consciousness3. Review of the procedures and manuals for preventing human errors and thorough implementation of compliance4. Other

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August 2005A “Safety Advisory Group” was established

Establishment of a Safety Advisory Group

Problems of an organization are difficult to find from inside the organization, or difficult to point out even if they are found.

Mr. Kunio Yanagida (Chair)Writer, critic

Mr. Yotaro HatamuaProfessor, Kogakuin UniversityProfessor Emeritus, University of Tokyo(specializes in “creative engineering” and “learning from failure”)

Mr. Shinichi KamataProfessor, National Defense Academy(specializes in “organizational theory” and “business administration”)

Mr. Shigeru HagaProfessor, College of Contemporary Psychology, Rikkyo University(specializes in “traffic psychology” and “industrial psychology”)

Mr. Akinori Komatsubara Professor, Faculty of Science and Engineering, Waseda University(specializes in “human life engineering”)

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December 2005We received a “Recommendation for Revival as a Company with a High Safety Standard.”

Recommendations from the Safety Advisory Group

December 2009We received a new recommendation entitled “Guard the Stronghold of Safety.”

Proposal of a concrete undertaking aimed at a specific corporate culture, at creating a specific working atmosphere

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Outline of the recommendation

Organizational reform: establishment of a central body responsible for safety

Reform in the way of thinking: having the viewpoint of families or passengers

Lessons learned from accidents: establishment of a Safety Promotion Center

Communication: look for breakthrough wordsand so on

Recommendations from the Safety Advisory Group

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Outline of the new recommendationConcept of “safety layer”4 pillars of “safety culture”Culture of decision-making by yourself and taking on challengesCulture of maintaining communicationCulture of refining the manualsCulture of having the “viewpoint of the 2.5th

person”and so on

Recommendations from the Safety Advisory Group

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Strengthening the Safety Organization Structure

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Establishment of a Central Safety Organization (Corporate Safety & Security Division)

Recommendation

The division responsible for safety and the corporate planning division are the engines on the wings that drive the company

Establish a central organization responsible for safety as a powerful “general staff office” for the top management

In April 2006, a “Corporate Safety & Security Division,” consisting of professional staff members knowledgeable of field works of operation, maintenance, cabins, airports and cargos, was established.

Using this organization as a source of power, drive a safety management structure across the whole group.

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Corporate Safety & Security DivisionCorporate Safety & Security Division

Operation Group 14 members

Safety Planning Group 16 members

Casualty Care Office 4 members

41 members in total

One Director, 6 Dept. Managers

(as of October 1, 2013)

Corporate Safety & Security Division

A contact service for bereaved families and casualties

Performs planning, safety audit, etc. related to aviation safety and aviation security

Performs the division’s operations in general, operation of the Safety Promotion Center, operation of safety promotion/education, etc.

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Establishment of a Central Safety Organization (Corporate Safety & Security Division)

Safety promotion at the head office level

Safety promotion at levels of field works/companies

Operations Dept.Operations Dept.Airport Planning Dept.

Airport Planning Dept.Maintenance Control

Dept.

Maintenance Control Dept.Cabin Safety

Promotion Dept.

Cabin Safety Promotion Dept.Operation Safety

Promotion Dept.

Operation Safety Promotion Dept.

Cargo & Mail Division

Cargo & Mail DivisionAirport DivisionAirport DivisionMaintenance

Division

Maintenance DivisionOperation

Division

Operation Division

Operation crew, cabin crew, mechanics, ground operation staff, airport staffOperation crew, cabin crew, mechanics, ground operation staff, airport staff

JEXJEX

JAIRJAIRJACJAC

RACRAC

JTAJTA

Operation Safety Committee

Operation Safety Committee Cabin Safety

Committee

Cabin Safety Committee Maintenance Safety

Committee

Maintenance Safety Committee Airport Safety

Committee

Airport Safety Committee Cargo Safety

Committee

Cargo Safety Committee

Aviation Safety Promotion CommitteeAviation Safety Promotion Committee

Safety Measure CouncilSafety Measure CouncilPresidentPresident

Corporate Safety & Security DivisionCorporate Safety & Security Division

Cabin DivisionCabin Division

Group airlines

Safety Management Structure of the JAL Group

Company-wide safety promotion

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Establishment of a Council Structure

Creation of a Safety Measure Council

In March 2005, the council was established with as its members: the President, vice-presidents, the safety supervisor, directors responsible for safety, and directors responsible for operations, maintenance, cabins, airports and cargos.

Safety Measure Council

Safety Measure Council

PresidentPresident

Aviation Safety Promotion Committee

Aviation Safety Promotion Committee

(Board of Directors)

Undertakings (meetings 1~2 times a month): policy decisions and quarterly review of important aspects of safety (course of action, safety objectives, safety policy) among others, sharing of safety data, verification of unsafe event handling, etc.

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Safety Management System

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Method for Safety Management – Excerpt from the Safety Management Rule –

Conduct continuous review of the Conduct continuous review of the Safety Safety Management SystemManagement System, and pursue , and pursue maintenance/improvement of safety of air maintenance/improvement of safety of air transport, by implementing efforts for a transport, by implementing efforts for a safety management cyclesafety management cycle..

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Safety Management CycleSafety Management Cycle

Spiral Up

•• Review and continuous improvementReview and continuous improvement•• Successful undertakings outside the company are vigorously documSuccessful undertakings outside the company are vigorously documented upon ented upon

and used as reference material. and used as reference material.

[PDCA cycle]

Safety Management CycleSafety Management Cycle (PDCA cycle)(PDCA cycle)

Safety policy

Evaluation and improvement of measures

Collection of information

Implementation of measures

Grasping/analysis of problems

Study of measures

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Safety promotion at the head office level

Safety promotion at levels of field works/companies

Operations Dept.Operations Dept.Airport Planning Dept.

Airport Planning Dept.

Maintenance Control Dept.

Maintenance Control Dept.

Cabin Safety Promotion Dept.

Cabin Safety Promotion Dept.

Operation Safety Promotion Dept.

Operation Safety Promotion Dept.

JEXJEX

JAIRJAIRJACJAC

RACRAC

JTAJTA

Group airlines

Operation Safety Committee

Operation Safety Committee Cabin Safety

Committee

Cabin Safety Committee Maintenance Safety

Committee

Maintenance Safety Committee Airport Safety

Committee

Airport Safety Committee Cargo Safety

Committee

Cargo Safety Committee

Aviation Safety Promotion CommitteeAviation Safety Promotion Committee

Safety Measure CouncilSafety Measure CouncilPresidentPresident

Corporate Safety & Security Division

A CDP

A CDP

A CDP

A CDP

A CDP

ACDP

ACDP

ACDP

ACDP

ACDP

Safety Management CycleSafety Management Cycle

Cargo & Mail Division

Cargo & Mail DivisionAirport DivisionAirport DivisionMaintenance

Division

Maintenance DivisionOperation DivisionOperation Division

Cabin DivisionCabin Division

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Management of Safety RisksManagement of Safety Risks

Reactive•Accident/serious incident investigation•Mandatory reporting system•Interview program, etc.

Proactive•Voluntary reporting system•Safe roving•Machinery/material quality monitoring, etc.

Predictive•Operation monitoring (Flight Data Monitoring, LOSA, Maintenance Operation Monitor, etc.)

Safety promotion

Ope -ration

Cabin Mainte -nance

Airport Cargo Group airlines

+

Safety information database

Information collection

Hazard identification and management

• Risk management is affected by the quality, the quantity and the speed of the information

• Data must be gathered, shared and put to use

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Evaluation of Safety RisksEvaluation of Safety Risks

Risk = Severity × ProbabilityRisk = Severity × Probability* Severity

[Index (examples)] Impact on flights, impact on customers, impact on the environment, degree of casualties, degree of reputation/media coverage

* Probability[Index (examples)] Occurring 2 to 3 times a week, occurring 2

to 3 times a year, occurring 2 to 3 times a decadeSeverity

Probability

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Safety Risk Matrix Safety Risk Matrix (Example)

SeverityProbability 5 4 3 2 1

5 A A B B C

4 A B B C C

3 B B C C D

2 B C C D D

1 C C D D D

Risk level Description Action

A Extreme Risk(Unacceptable)

Immediately interrupt the respective operation/project (or after taking an emergency action), take a measure to reduce the risk to an acceptable level.

B High Risk(Unacceptable)

Formulate a measure to control the risk to an acceptable level as soon as possible, and implement the measure.

C Medium Risk(Tolerable)

Implement a measure to control the risk to an acceptable level in a planned manner (specify the plan).

D Low Risk (Acceptable)

Unnecessary to take any particular action.・Set a matrix for each areas

・Also evaluate possible worst cases

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Reduction of Safety RisksReduction of Safety Risks

Risk reductionFormulation/implementation of risk reduction measures according to risk levelsRecurrence prevention PDCA checklist•Validation of the reduction measures•Lateral spread among the Group

(draw a lesson from the information)

•Reviewing the effect after implementation

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Safety Indexes and Safety Goals of the JAL GroupSafety Indexes and Safety Goals of the JAL Group

JAL Group safety indexes

Number of aviation accidents

Number of serious incidents

Number of irregular flights

Number of injuries to customers

Number of defects due to human errors

Management of other indexes・Visualization of safety level・Index showing employee efforts・Undertakings to thicken safety layers

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Continuous Improvement of the Safety Continuous Improvement of the Safety Management SystemManagement System

Comprehensive information collection

Defect eventsSafety indexesSafety promotion council structuresField investigation (safe roving, operation investigation)Business plan (change in the business environment)Recommendations from the Safety Advisory GroupTransport safety management evaluationAudit by the Civil Aviation Bureau, IOSA, and code-sharing partnersOther

Analysis

Evaluation

Audit summary

・Extraction of problems・Checking the improvement measure (direction)

Safety measure

Implementatio n of

improvement action

Safety audit (internal audit)

・Extract essential problems such as those with organizations and safety culture・From compliance to performance basis

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Fostering a Safety CultureFostering a Safety Culture

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A safety culture is a “habit of mind”

A safety culture is created from the viewpoint of passengers

Excerpt from the recommendation by the Safety Advisory Group

Fostering a Safety Culture

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Culture of repotting

Example: voluntary reporting system

Culture where necessary information reaches all parts of the organizationExample: lateral spread and sharing of safety information

Fair cultureCulture of learningExample: Safety Promotion CenterFacilitator education

Safety Management

Cycle

Non-disciplinary policy

Viewpoint of the 2.5th

personMaintain the memories of accidents

Top management’s commitment

Fostering a Safety Culture

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Culture of repotting

Example: voluntary reporting system

Culture where necessary information reaches all parts of the organizationExample: lateral spread and sharing of safety information

Fair cultureCulture of learningExample: Safety Promotion CenterFacilitator education

Safety Management

Cycle

Non-disciplinary policy

Viewpoint of the 2.5th

personMaintain the memories of accidents

Fostering a Safety Culture

Top management’s commitment

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Top Management’ Commitment

Safety Charter

Safety in flight operations is the very foundation and social responsibility of the JAL Group.To carry out our mission of assuring safety, the management will exert its strong resolve and the employees will bear an awareness of their individual roles and responsibilities, and together we will combine our utmost knowledge and capabilities to ensure the safety and reliable operation of each and every flight.

In order to carry out our mission, we will conduct;Perform our duties in compliance with regulations, faithfully following the basics.Be sure to make checks, without relying on assumptions.Relay information thoroughly, promptly and accurately, and ensure transparency.Respond to problems and issues quickly and precisely.Maintain a constant awareness of issues, and make necessary reforms without hesitation.

JAL Group Safety Charter

Management’s commitment and strong resolve

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Culture where necessary information reaches all parts of the organizationExample: lateral spread and sharing of safety information

Culture of learningExample: Safety Promotion CenterFacilitator education

Safety Management

Cycle

Viewpoint of the 2.5th

personMaintain the memories of accidents

Top management’s commitment

Fostering a Safety Culture

Culture of repotting

Example: voluntary reporting system

Fair culture

Non-disciplinary policy

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Minor human errors with which safety problems have not surfaced (that have not resulted in major problems) will be buried without being reported. However, even such minor errors may develop into major problems if they occurred in different circumstances.

Therefore, it is important to analyze even minor human errors and utilize them for preventive measures in order to prevent major problems from occurring. A system for collecting such minor human errors is the voluntary reporting system (*).

(*) Introduce the system to operations involving operation crew, cabin crew, mechanics, airport staff and cargo services

Voluntary Reporting System

Gather even limited data

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If the person making such an error is punished, the workplace will stagnate and the lesson learned will not easily be shared.

To ensure that the interview program and the voluntary reporting system will effectively work, it is necessary to establish a rule under which reporters shall not be internally disciplined.

Non-disciplinary Policy

Introduced to the JAL Group in February 2007

Gather accurate data

Excerpt from the recommendation by the Safety Advisory Group

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Culture of repotting

Example: voluntary reporting system

Fair cultureCulture of learningExample: Safety Promotion CenterFacilitator education

Safety Management

Cycle

Non-disciplinary policy

Viewpoint of the 2.5th

personMaintain the memories of accidents

Top management’s commitment

Fostering a Safety Culture

Culture where necessary information reaches all parts of the organizationExample: lateral spread and sharing of safety information

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Communication on SafetyCommunication on Safety

Corporate Safety (e.g., business message, state of safety goal achievement) [transmitted 20 times]

Corporate Safety Information (lateral spread of safety information among companies/divisions) [transmitted 15 times]

Full-time disclosure of safety information via the intranet (e.g., state of safety goal achievement)

Workplace rounds by executives [180 times]

Summer safety campaign

Thorough safety examination of year-end/ new-year transport

Face-to-face dialog by the Safety Advisory Group

Face-to-face dialog with employees [20 times]

Feedback to the management [twice]

Communication leader meeting [11 times]

・Share the acquired information, and draw a lesson from it.・Vocal communication is the basics.

Figures in [ ] are FY 2012 results

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Culture of repotting

Example: voluntary reporting system

Culture where necessary information reaches all parts of the organizationExample: lateral spread and sharing of safety information

Fair cultureCulture of learningExample: Safety Promotion CenterFacilitator education

Safety Management

Cycle

Non-disciplinary policy

Maintain the memories of accidents

Top management’s commitment

Fostering a Safety Culture

Viewpoint of the 2.5th

person

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Make judgment while attaching importance to affection and consideration.Act in tune with each individual without sticking to conventional rules.Respond according to individual requests/circumstances of customers.

Viewpoint of the 2nd

person If your family were a customer

Viewpoint of 1st

person If you were a customer

“Viewpoint of the 2.5th Person”

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Make expert judgment as a professional in a calm manner.Perform your work while faithfully observing what are written in the rule.Respond without being influenced by various requests/circumstances of customers.

Viewpoint of the 3rd person Calm and dry viewpoint

“Viewpoint of the 2.5th Person”

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Viewpoint of the 2.5th person Calmly perform your duties from the “viewpoint of the 3rd person” as a professional while at the same time having the “viewpoints of the 1st and 2nd person”

It is important to always act from the other person’s viewpoint

“Viewpoint of the 2.5th Person”

To be able to act spontaneously, acquire the “habit of mind” by having the way of thinking from the “viewpoint of the 2.5th person” on a regular basis.

Instead of thinking that you “should only do what are written in the rule” and automatically responding, always act from a different viewpoint by staying a while to think if “there is anything else I can do” and if “it is necessary to check again.”

The motivation to improve safety

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Culture of repotting

Example: voluntary reporting system

Culture where necessary information reaches all parts of the organizationExample: lateral spread and sharing of safety information

Fair culture

Safety Management

Cycle

Non-disciplinary policy

Viewpoint of the 2.5th

person

Top management’s commitment

Fostering a Safety Culture

Culture of learningExample: Safety Promotion CenterFacilitator education

Maintain the memories of accidents

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Date Flight name, model Place Outline of the accident Number of casualties

April 9, 1952 JAL301, Martin 202Mokusei-go

Izu Oshima Island

Collided to Mt. Mihara of the Izu Oshima Island on the projected course

37 passengers and crew members were all killed

July 3, 1971 TDA63, YS-11ABandai-go

Hakodate Crashed into the south slope of Mt. Yokotsudake while approaching to the Hakodate Airport

68 passengers and crew members were all killed

June 14, 1972 JAL471, DC-8-53 New Delhi Slammed to the bank of the Yamuna River before the Palam Airport

86 passengers and crew members were killed and 3 seriously injured

November 28, 1972

JAL446, DC-8-62 Moscow Crashed immediately after taking off from the runway of the Sheremetyevo Airport

62 passengers and crew members were killed and 14 seriously injured

January 13, 1977

JAL1045, DC-8-62F Anchorage Crashed immediately after taking off from the Anchorage Airport

5 passengers and crew members were all killed

September 27, 1977

JAL715, DC-8-62 Kuala Lumpur Collided to a hill before the Kuala Lumpur airport while descending to approach the airport

34 passengers and crew members were killed and 45 seriously injured

February 9, 1982

JAL350, DC-8-61 Haneda Crashed into a shallow water of the Tokyo Bay off the runway C while landing

44 passengers were killed and 149 seriously injured

August 12, 1985

JAL123, 747 Gunma Prefecture

Crashed into the ridge of Mt. Osutaka in Gunma Prefecture

520 passengers and crew members were killed and 4 seriously injured

Accidents of the JAL Group

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JL123 (JA8119) crash accident

Around 18:56 on Aug. 12, 1985, the airplane crashed into a mountain (Mt. Osutaka) in Gunma Prefecture.

The airplane got out of control because all hydraulic systems became inoperable due to partial loss of the vertical tail and the rear fuselage as a result of breakage of the rear bulkhead.

The cause was a defective work performed by Boeing during a repair after accidental contact of the tailpiece at the Itami Airport in 1978 (summary of the Transport Ministry's Aircraft Accident Investigation report )

Of the 524 people on board,520 (505 passengers and 15 crew

members) were killed, and 4 survived

Starting Point of Our Approach to Safety

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Creating a corporate climate of securing safety with the Mt. Osutaka accident as the starting pointEducation on “gen-chi (site),” gen-butsu (real thing) and gen-jin (living people)”“Gen-chi (site)”: Mt. Osutaka

ridge climbing

“Gen-butsu (real thing)”: Safety Management Center tour

“Gen-jin (living people)”: Messages from bereaved families and from employees who engaged in the accident at that time

The idea is that you can understand the true nature of things only by actually visiting the site (gen-chi), seeing the real things (gen-butsu) and listening to those who experienced the accident (gen-jin) (*).

(watching educational material consisting of video images of interviews with bereaved families and employees)

* Source: Safety Advisory Group’s recommendation – Annex by member Yotaro Hatamura

Maintaining the Memories of Accidents

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Safety Promotion Center

Number of visitors (as of end of August 2013)Total: 129,766 people (employees account for 50%)

On April 24, 2006, a “Safety Promotion Center” was opened.

Keep the lessons learned from this accident in our minds , and hand them down to the next generation

Promote safety consciousness among JAL Group employees

The shape of safety cannot be displayed. Results of being unsafe will be visualized.

Closed for relocation and construction f

or 3 months since October 1, 20130

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This education has been conducted for all the 36,000 employees of the JAL Group for approximately two years.“Make the safety layer thicker” by accumulating awareness and actions through the safety declaration.

“Learn about, be conscious of and think about” the Mt. Osutaka accident

JAL Group’s Safety EducationOutline of the education

Learn lessons from past accidents

Set your own “my safety declaration” before returning to your workplace.

Think about the connection between your duties and safety.

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Thank you very much for your attention.