Breaking the Barriers to a Generative Culture
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Breaking the Barriers to a Generative Culture
CHC Safety & Quality Summit
Vancouver – 2014
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Culture – the final frontier.
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Why a Generative Culture?
• Typical human:– Resists change– Seeks cognitive ease– Acts out of habit 95% of the time
• Habits create culture.• People tend to act out of cultural norms.• A generative culture can deliver habit-strength
safe behaviors.
Basal Ganglia
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The Whole System for Safety
• Goal• Strategy• Structure• Culture
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International Helicopter Safety Team
• Initial goal set in 2006: reduce the global accident rate by 80% within the next 10 years
• Current vision: an international civil helicopter community with zero accidents
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OGP Safety Commitment (2004)
“The individual risk per period of flying exposure for an individual flying on OGP contracted business should be no greater than on the
average global airline.”
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Completing the Mission Safely
• Goal
• Strategy• Structure• Culture
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• New helicopters• Training• Quality and safety management systems• Health & Usage Monitoring Systems (HUMS)• Flight Data Monitoring (FDM)• Disciplined take-off and landing profiles• Avionics to prevent CFIT and mid-air
collisions (EGPWS/TAWS & TCAS/ACAS)
OGP Air Safety Strategy
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IHST Focus Areas
• Safety Management Systems (SMS)• Training• Systems & equipment
Health monitoring systems (HUMS)Flight data monitoring (FDM) systems
•Maintenance
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Completing the Mission Safely
• Goal• Strategy
• Structure• Culture
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Support Structure• Proactive Hazard Identification & Management
• Supporting Policies, Procedures, Measures and Controls
• Pre-flight risk assessment
• Operating controls
• Competent resources – effectively organized
• People
• Equipment
• Open reporting in a Just Culture
• Root cause investigation and corrective actions
• Safety promotion and information sharing in a Learning Culture
• Audits and reviews for continuous improvement
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SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
QUALITY SYSTEM – UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION &
EFFECTIVENESSOF CONTROLS
SAFETY REPORTING & INVESTIGATION
PROCESS NEW HAZARDS
MANAGEMENT OF CHANGE
PROCESS
MANAGEMENT REVIEW
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
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Detailed RAM
once
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Safety BowtieHAZARD
CONSEQUENCERELEASE
OF HAZARD
Barrier
Barrier
Control
Control
Recovery
Measure
Recovery
Measure
Recovery
Measure
Recovery
Measure
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Support Structure• Proactive Hazard Identification & Management
• Supporting Policies, Procedures, Measures and Controls
• Competent resources – effectively organized
• Open reporting in a Just Culture
• Root cause investigation and corrective actions
• Safety promotion and information sharing in a Learning Culture
• Audits and reviews for continuous improvement
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Audits & Review
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Results?
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2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
2
4
6
8
10
12
14
Oil & Gas Industry Fatal Helicopter Accident Rates
Oil Industry FAR ex-OGP ASC Oil Industry FAR OGP ASC FAR
Fata
l A
ccid
ents
per
Mill
ion F
lyin
g H
ours
Fatal Accident Rate (FAR) per million flying hours - five-year rolling average
There are statistically significant dif-ferences between the industry and the OGP Aviation SubCommittee (ASC) trends.
Total Oil -/Gas Industry
Rest of Oil -/Gas Industry
Aviation Subcommittee Members
Source: International Association of Oil & Gas Producers Aviation Subcommittee
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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 20160
100
200
300
400
500
600
700
Global Civil Helicopter Accidents
Pre-IHST Accidents Pre-IHST Trend Baseline AveragePost-IHST Accidents Post-IHST Trend Milestones
Average of 587 accidents per year from 2001 thru 2005
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“Culture is set by the guy who pays the
bills.”Lee Benson, Former Chief Pilot for the
Air Operations Section of the Los Angeles County Fire Department
Peter Drucker
“Culture eats strategy for breakfast.”
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Culture
Culture: The Mother of all Root Causes
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The Safety Culture Ladder
Reference: Hearts & Minds - http://www.eimicrosites.org/heartsandminds/
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Generative Culture
• Mindfulness– Alert caution– Compliance
• Learning– Reporting– Just Culture
• Continuous improvement– Sharing internal & external information– Collaboration
#1 Question:Can people talk
about their concerns?
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Cultural Changes
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The Tipping Point
CRITICAL MASS
Communication channels must provide:knowledge,persuasion, decision, implementation, and confirmation
Reference: Everett Rogers
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Requirements for Change
• Relative Advantage
• Compatibility
• Simplicity
• Trial ability
• Observability
Reference: Dr. Everett M. Rogers, Diffusion of Innovations
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Changing Habits
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At the Root
Beliefs
Behaviors
Habits
Culture“Great leaders talk about their beliefs and attract
people who believe what they believe.”- Simon Sinek
Do people in your workplace talk about their
beliefs about safety?
“People don’t resist change,
they resist being changed.”
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Ego
From An Invitation to Enter the Now by Sami Cohen
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Role Play Scenario
Captain• 19,000 total hours• ATPL• Multiple Type Ratings• Chief Pilot until 31 July
First Officer• 19,100 total hours• ATPL• Multiple Type Ratings• Chief Pilot after 31 July
Weather100’ broken with 1,600 feet RVR
MissionEn route to pick up a Very, Very Important Person
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Questions
• Cues?• Routines?• Rewards?• Desires or beliefs supporting the routines?• The role of the egos?
Feel free to speculate!
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ILS Approach to Runway 4
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CVR & Flight PathTime Comments State of Flight
05:58:50 Houston Terminal Radar Approach Control (TRACON) cleared the flight directly to CARCO, adding, “when you’re able for the ILS runway four.”
18,000 feet headed southeast
06:05:05 TRACON instructed “descend to and maintain 3,000 feet”
11,000 feet headed southeast
06:10:43 TRACON instructed the flight crew to turn left heading 070° and to maintain an altitude of “2,000 feet or above ‘til established[on the] localizer.”
Descending on a southeasterly heading
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CVR & Flight PathTime Comments State of Flight06:11:13 The First Officer stated “localizer’s
alive.”Descending through 2,900 feet and turning left
06:11:57 First Officer contacted the HOU air traffic control tower (ATCT) and stated “with you on the ILS.”
Descending through 2,300 feet and turning left
06:12:15 Captain told First Officer “I can’t get approach mode on my thing.”
Descending and turning left
06:12:57 First Officer says “what [is] wrong with this?” Captain replies “I don’t know.”
Descending and turning left, 600 to 1,000 feet below the glideslope
Cues?Routines?Rewards?Beliefs?Egos?
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Stress
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CVR & Flight PathTime Comments State of Flight06:13:03 First Officer says “what do we have
set wrong? We have…long range [navigation or NAV] or something… that we shouldn’t have?”
Descending and turning left, 600 to 1,000 feet below the glideslope
06:13:08 The Captain reported, “got NAV…VOR one.”
Descending and turning left, 600 to 1,000 feet below the glideslope
06:13:10 The First Officer stated, “okay, we’re high on the glideslope now,” and the Captain replied, “just gonna have to do it this way.”
Descending and turning left, 600 to 1,000 feet below the glideslope
Cues?Routines?Rewards?Beliefs?Egos?
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Avionics
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CVR & Flight PathTime Comments State of Flight06:14:05 The Captain asked “what
happened? did you change my frequency?” The first officer responded, “yeah we were down there…the VOR frequency was on.” He then stated, “we’re all squared away now…you got it.” The captain responded, “yeah, but I, I don’t know if I can get back on it in time.” The first officer replied, “yeah you will…you’re squared away now.”
Intercepting localizer course and descending through 900 feet, 800 feet below the glideslope
06:14:45 First Officer “Up, up, up, up, up, up, up”
06:14:47 Impact with a light pole.
Cues?Routines?Rewards?Beliefs?Egos?
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Lessons?
• One thing?• One more thing?
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Training for Habit-Strength Safe Behaviors
Routine
Cue RewardBeliefs & Desires
Recognition ImmediatePositiveCertain
Deep Understanding
Substitution
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Focus
1) Biggest risks2) Good & bad routines3) Good & bad cues4) Rewards5) Shared beliefs
Train to habit strength on• Motor skills• Technology• MindsetLeverage “keystone habits”
Routine
Cue RewardShared Beliefs
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Focus
Correlation between numbers:
Big Change Efforts Big Change Successes
• 3 3
• 5 < 5
• > 5 < 3
• > 10 0
• One thing at a time
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Safety BowtieHAZARD
CONSEQUENCERELEASE
OF HAZARD
Barrier
Barrier
Control
Control
Recovery
Measure
Recovery
Measure
Recovery
Measure
Recovery
Measure
Threats
Threats
Cues?
Cues?
Routines
Rewards
Routines
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Leverage
What is the one thing you can do such that by doing it everything else will be
easier or unnecessary?
Reference: The One Thing by Gary Keller
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Zero Accidents
• Goal or Vision
• Strategy
• Structure
• Culture Le
ader
ship
Follo
wersh
ip
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References
• Energy Institute, Hearts and Minds, http://www.eimicrosites.org/heartsandminds/
• Professor Patrick Hudson• Simon Sinek, Why and
http://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action.html
• Daniel Kahneman, Thinking, Fast and Slow
• Daniel Goleman, Focus• Charles Duhigg, The Power of Habit• Dr. Richard Restak, The Naked Brain
and Mozart’s Brain and the Fighter Pilot
• Dr. Everett Rogers, The Diffusion of Innovations
• Sami Cohen, An Invitation to Enter the Now
• NASA report on GIII Crash on Approach to Houston Hobby on 22 November 2004,http://www.ntsb.gov/doclib/reports/2006/aab0606.pdf
• Bob Williams, Aviation Advisor, Field Support Services, ExxonMobil Aviation Services (OGP data)
• International Helicopter Safety Team (www.ihst.org)
• Gary Keller, The One Thing
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Summary
• Helicopters save lives and do vital work, but the global helicopter accident rate is still unacceptable.
• Culture dominates!• You can change the culture:
– Discuss beliefs and share the vision of zero accidents– Train for habit-strength safe behaviors– Find and leverage the “keystone habits”– Make it safe to express concerns– Spread the word
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Breaking the Barriers to a Generative Culture
CHC’s Safety & Quality Summit
Vancouver – 2014
Questions?
Thank you!