Just Culture
I'm Facebook mates with 3 of my old sqn bosses. I send Christmas cards to these and I share a beer with all of my ex sqn bosses every year...
I am still in touch with three of my former sqn cdrs and regularly see them at formal and informal reunions. Mind you, we all emanate from the era when we had leaders and commanders, rather than managers and executives!
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Originally Posted by high spirits
The trouble with the system of DASOR is that every career chiseling bluntie gets to put his two penneth in because he once flew on ops. The amount of senior officers who 'climb into your cockpit' and pretend that they wouldn't have made the same decision as you is staggering.
They only do it so that they can get noticed putting the boot in. Nothing to do with learning lessons on AS. Stop it you burks....
They only do it so that they can get noticed putting the boot in. Nothing to do with learning lessons on AS. Stop it you burks....
Originally Posted by Dan Winterland
The big problem for military Flight Safety is the "alpha male'' commander/manager type that exists within the command structure. Their tenure is short and they don't want anything happening to bugger up their chances of promotion on their watch. This pervades the whole system - all they way to the top They want to know everything and are only too happy to apportion blame where they see fit - and which is rarely on their own doorstep.
Interestingly, I hear EasyJet have a model safety culture that has borne dramatic reductions in accidents/incidents as the culture prevailed. As a result they have saved a fortune in operating costs, let alone potential lives. But as my source made clear, and as several have said here, you can't just declare a culture in SROs - it has to be nurtured, which means those who turn to it in the spirit intended are genuinely supported by senior officers who have the integrity to see the end game as more important that their pensions. Or is that the underlying snag?
Last edited by dallas; 1st Nov 2013 at 18:13.
Dallas,
You are correct in saying that it isn't just "the system" that works - its the people driving it (those at the top?) who matter just as much as the system. Replace one or two of those key drivers and the system is almost always going to slip until someone else gets a grip with how to handle it. Put the wrong people in and it will collapse.
I know one of those EasyJet SMS people and he is a great driver.
"A man can do one thousand good things but he will be remembered for the one thing he does wrong."
You are correct in saying that it isn't just "the system" that works - its the people driving it (those at the top?) who matter just as much as the system. Replace one or two of those key drivers and the system is almost always going to slip until someone else gets a grip with how to handle it. Put the wrong people in and it will collapse.
I know one of those EasyJet SMS people and he is a great driver.
"A man can do one thousand good things but he will be remembered for the one thing he does wrong."
Just culture? Not always. If it were, no one would have to submit a DASOR to the Sqn executive before pressing send.
Now, loose or sloppy wording in a DASOR should not be a problem... the point of the system is to get occurrences recorded, and if the language is somewhat less than perfect, so what. Unfortunately the early days of ASIMS showed that if indignant ivory tower-dwellers could detect even a sniff of human failing then critical comments and requests for further clarification would inevitably follow. I think some units came to the view that it was worth the effort to put out a water-tight DASOR at the first time of asking, rather than go round in circles wasting supervisory capacity trying to un-f*** the mess that can arise from a quickfire submission.
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At a bizjet company I worked for it was seen as an indicator of good departmental management to have a healthy number of incident/occurence reports, as this was viewed as providing an opportunity to spot patterns and manage safety, thus saving money/rep/lives as the long term win. Staff were almost chased to submit stuff, and the FS team genuinely looked at each report as a learning opp. Perhaps this should be introduced as a KPI for mil commanders too - it would certainly force through the culture and be an antidote to chisselers at different levels, if they viewed no. of reports as a scorecard.
Last edited by dallas; 2nd Nov 2013 at 07:25.
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Dallas
Easyjet is undoubtedly a well run airline from an air safety point of veiw with the number of incidents driven to a very low level.
However I get the feeling that they have driven down the number of incidents by a ridged procedural flying policy and discouraging manual flying, my evidence for this is that they usually are very reluctant to take a visual approach even when the conditions are very good VMC. Approaches to Nice are a good example I always seem to be behind an EZY who is insisting on doing the full VOR approach when all I want to do is fly around the cap Antibes and land. May be I'm just unlucky and have a new first officer on line training in the EZY in front of me.
The situation the military have is that the operation is incompatable with a very ridged procedural system and has to encourage the basic hand flying skills rather than use of autopilots, by the very nature of the operation, military flying will have more inccidents and so puts an even greater strain on those trying to instill a blame free culture.
However I get the feeling that they have driven down the number of incidents by a ridged procedural flying policy and discouraging manual flying, my evidence for this is that they usually are very reluctant to take a visual approach even when the conditions are very good VMC. Approaches to Nice are a good example I always seem to be behind an EZY who is insisting on doing the full VOR approach when all I want to do is fly around the cap Antibes and land. May be I'm just unlucky and have a new first officer on line training in the EZY in front of me.
The situation the military have is that the operation is incompatable with a very ridged procedural system and has to encourage the basic hand flying skills rather than use of autopilots, by the very nature of the operation, military flying will have more inccidents and so puts an even greater strain on those trying to instill a blame free culture.
Sorry dallas, but to make the input of reporting a KPI is the exact opposite of what you should do, there is talk of doing that around where I work, the problem with getting as many as you can into the system so it looks like you have a just culture is the system gets swamped and as no one can afford to sustain a healthy clearance rate, due to financial and commercial constraints mostly.
Closing the issues out in the correct manner to satisfy the person who put the issue in is the most imperative part of the process, if you don't close them and put the right process/equipment/people in place people get disillusioned and give up on the system and then you run the risk of missing the one that will stop the accident happen, which is even worse than not meeting the KPI.
Again a KPI was being muted for closure rates, but this is also unattainable and impracticable for all the reasons already stated.
You can also end up with open legacy issues and trust me you can get personnel to put all sorts into the system if you push them hard and long enough, and a lot of those should not and do not need to be put in as there are other methods of raising those through audits, suggestions boxes, GEMs etc, having a form of KPI to be met was attempted with Health and Safety kaizons and that was not very successful and is not utilized.
Back to the financial/commercial and dependency issues when it becomes to difficult it is either closed with some lame excuse or put onto the Risk Register or Hazard Log and that is also considered the issue sorted.
Closing the issues out in the correct manner to satisfy the person who put the issue in is the most imperative part of the process, if you don't close them and put the right process/equipment/people in place people get disillusioned and give up on the system and then you run the risk of missing the one that will stop the accident happen, which is even worse than not meeting the KPI.
Again a KPI was being muted for closure rates, but this is also unattainable and impracticable for all the reasons already stated.
You can also end up with open legacy issues and trust me you can get personnel to put all sorts into the system if you push them hard and long enough, and a lot of those should not and do not need to be put in as there are other methods of raising those through audits, suggestions boxes, GEMs etc, having a form of KPI to be met was attempted with Health and Safety kaizons and that was not very successful and is not utilized.
Back to the financial/commercial and dependency issues when it becomes to difficult it is either closed with some lame excuse or put onto the Risk Register or Hazard Log and that is also considered the issue sorted.
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A and C
Yes, that's true re: EZY, and safety is a lot easier to manage with a scheduled service or pattern, but there are still a lot of commonalities remaining between types, units, commands and arms. And even then, best practice can be developed to apply to greyer situations, based ideally on previous experiences and incident/accident reports.
I think it's interesting that 15ish years ago the RAF would have been hailed as a paragon of flight safety, with Air Clues etc often being sought by civvies for training, and yet somehow it now finds in itself on the back foot in terms of culture to EZY et al - notwithstanding your observation above. I wonder if the next big enquiry will ever connect the shrinking size of the services to narrower oversight mechanisms that became contaminated with ambitious individuals; the latter certainly buggered up a lot of other stuff!
I think it's interesting that 15ish years ago the RAF would have been hailed as a paragon of flight safety, with Air Clues etc often being sought by civvies for training, and yet somehow it now finds in itself on the back foot in terms of culture to EZY et al - notwithstanding your observation above. I wonder if the next big enquiry will ever connect the shrinking size of the services to narrower oversight mechanisms that became contaminated with ambitious individuals; the latter certainly buggered up a lot of other stuff!
The point of getting lots of reports into the system (and to make the reporting levels a KPI) is to get staff generating reports and used to the idea of submitting them. The fact that you're still doing this signifies that you're still in the "Reporting Culture" or earlier stages and a fair few cultures away from being "Just".
Does that spinning Campbell chap do the PR for the SMS system now?
I think EZY goes for the earliest stabilised approaches to get their fuel costs down too.
Does that spinning Campbell chap do the PR for the SMS system now?
I think EZY goes for the earliest stabilised approaches to get their fuel costs down too.
Which explains why Leon went from Plt Off to Wg Cdr in 9 years!
LJ
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Rigga
The early stabilized approaches are less fuel efficient but the policy had advantages with insurance costs.
The constant descent approaches are the fuel saver with that ultimate aim being to glide from cruise altitude to touchdown, but in practice the power comes up to fight the drag as the aircraft is stabilized in landing configuration before 1000 ft AAL in line with company SOP.
The constant descent approaches are the fuel saver with that ultimate aim being to glide from cruise altitude to touchdown, but in practice the power comes up to fight the drag as the aircraft is stabilized in landing configuration before 1000 ft AAL in line with company SOP.
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What a cracking bit of fishing from Wg Cdr Spry, eh? Throws out the bait and sits back as the huddled masses throw it back out of the water
Sir, as the instructors on CATCS used to ask at the end of a sim slot "How do you think that went?" Not as well as you planned, or better?
As for me, I think my part of the organisation is in a pretty healthy learning phase; plenty of open, honest reporting uncovering some personal, managerial and procedural short-comings which can mostly be attended to locally and with minimal fuss. Is it Just? It is trying to be; awards and sanctions have both been dished out. Is it perfect? Far from it but it is effective. The important thing is that the Boss is making it happen by taking an interest and lending his weight where necessary; he is confident enough in us to let us sort most of it out and then report back. Long may that continue. If it does, then we will be on our way to lasting cultural change.
Sir, as the instructors on CATCS used to ask at the end of a sim slot "How do you think that went?" Not as well as you planned, or better?
As for me, I think my part of the organisation is in a pretty healthy learning phase; plenty of open, honest reporting uncovering some personal, managerial and procedural short-comings which can mostly be attended to locally and with minimal fuss. Is it Just? It is trying to be; awards and sanctions have both been dished out. Is it perfect? Far from it but it is effective. The important thing is that the Boss is making it happen by taking an interest and lending his weight where necessary; he is confident enough in us to let us sort most of it out and then report back. Long may that continue. If it does, then we will be on our way to lasting cultural change.
orgASMic, you are absolutely right about the importance of a good Boss, the most important person (or bloody well ought to be) in any military organisation.
Therein lies the W/C's dilemma, for the RAF Flight Safety organisation that he represents is founded on the assumption that all is well above, while it is those below who need to be educated and encouraged in matters of Safety. The recent history of the Royal Air Force though suggests that the opposite is the case, and sadly there is no mechanism for him to address that, as he has tacitly admitted on his sticky thread. Even if there were, the Star Chamber has more important considerations on its mind, ie covering up the sins of their forefathers lest they in turn be exposed.
That is why RAF Flight Safety needs to be completely reformed, by making Regulation and Investigation (the two means of ensuring it from above) independent of the MOD and of each other. The MAA and MAAIB should be sistered with the CAA and AAIB respectively to become the military sides of those two bodies and be led by civilian DGs with seconded Service personnel. That way his dilemma can be resolved and he can then get on with his job of educating and encouraging with the assurance that it can then work effectively.
Therein lies the W/C's dilemma, for the RAF Flight Safety organisation that he represents is founded on the assumption that all is well above, while it is those below who need to be educated and encouraged in matters of Safety. The recent history of the Royal Air Force though suggests that the opposite is the case, and sadly there is no mechanism for him to address that, as he has tacitly admitted on his sticky thread. Even if there were, the Star Chamber has more important considerations on its mind, ie covering up the sins of their forefathers lest they in turn be exposed.
That is why RAF Flight Safety needs to be completely reformed, by making Regulation and Investigation (the two means of ensuring it from above) independent of the MOD and of each other. The MAA and MAAIB should be sistered with the CAA and AAIB respectively to become the military sides of those two bodies and be led by civilian DGs with seconded Service personnel. That way his dilemma can be resolved and he can then get on with his job of educating and encouraging with the assurance that it can then work effectively.
