Breaking the Barriers to a Generative Culture

CHC Safety & Quality Summit

Vancouver – 2014

Culture – the final frontier.

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

The Whole System for Safety

• Goal• Strategy• Structure• Culture

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

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.”

Completing the Mission Safely

• Goal

• Strategy• Structure• Culture

• 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

IHST Focus Areas

• Safety Management Systems (SMS)• Training• Systems & equipment

Health monitoring systems (HUMS)Flight data monitoring (FDM) systems

•Maintenance

Completing the Mission Safely

• Goal• Strategy

• Structure• Culture

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

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

Detailed RAM

once

Safety BowtieHAZARD

CONSEQUENCERELEASE

OF HAZARD

Barrier

Barrier

Control

Control

Recovery

Measure

Recovery

Measure

Recovery

Measure

Recovery

Measure

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

Audits & Review

Results?

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

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

“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.”

Culture

Culture: The Mother of all Root Causes

The Safety Culture Ladder

Reference: Hearts & Minds - http://www.eimicrosites.org/heartsandminds/

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?

Cultural Changes

The Tipping Point

CRITICAL MASS

Communication channels must provide:knowledge,persuasion, decision, implementation, and confirmation

Reference: Everett Rogers

Requirements for Change

• Relative Advantage

• Compatibility

• Simplicity

• Trial ability

• Observability

Reference: Dr. Everett M. Rogers, Diffusion of Innovations

Changing Habits

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.”

Ego

From An Invitation to Enter the Now by Sami Cohen

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

Questions

• Cues?• Routines?• Rewards?• Desires or beliefs supporting the routines?• The role of the egos?

Feel free to speculate!

ILS Approach to Runway 4

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

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?

Stress

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?

Avionics

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?

Lessons?

• One thing?• One more thing?

Training for Habit-Strength Safe Behaviors

Routine

Cue RewardBeliefs & Desires

Recognition ImmediatePositiveCertain

Deep Understanding

Substitution

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

Focus

Correlation between numbers:

Big Change Efforts Big Change Successes

• 3 3

• 5 < 5

• > 5 < 3

• > 10 0

• One thing at a time

Safety BowtieHAZARD

CONSEQUENCERELEASE

OF HAZARD

Barrier

Barrier

Control

Control

Recovery

Measure

Recovery

Measure

Recovery

Measure

Recovery

Measure

Threats

Threats

Cues?

Cues?

Routines

Rewards

Routines

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

Zero Accidents

• Goal or Vision

• Strategy

• Structure

• Culture Le

ader

ship

Follo

wersh

ip

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

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

Breaking the Barriers to a Generative Culture

CHC’s Safety & Quality Summit

Vancouver – 2014

Questions?

Thank you!