We Need a Just Culture at JFK

8 03 2010

JFK airport is finally in the news, again, for something other than delays or a crash. It managed to make the headlines after a controller let his young son repeat instructions on frequency to departing aircraft, which is something that both Don Brown, of Get The Flick, and Rob Mark, of JetWhine, feel posed no signifiant threat to airport operations. Don is a retired Atlanta Center controller with 25 years under his belt, including time as the union safety representative. Rob is a reputable consultant with just as much to say about piloting and controlling as he has experience doing each. I trust their judgement and think they deserve a little more than just a fleeting glimpse if you’re looking for something to read.

The argument against firing or suspending the controller and his supervisor seems to center around the fact that this is an isolated incident (I’m pretty sure there’s no underground, grass-roots effort by controllers to have their children key the mic until they can negotiate a better contract). But like any other recent problem with the aviation industry, the dilemma is more systemic and chronic than localized and short-term. The safety culture of the FAA is suffering at the hand of flawed public perception and higher-ups who are feeling the squeeze from people who can’t see the human fallibility in occurrences like this.

An organizational culture is a set of behavioral norms (“the way we do things around here”, says Reason). It lies at the intersection of the way people feel (shared values and beliefs) and how the system operates (structure and control). Sometimes with this there is a tense relationship between the top and the bottom of the hierarchy, which is why we’re seeing a lot of talk about how to develop an effective safety culture that can dampen the likelihood of additional risks popping up because people are not on the same page. An informed safety culture is generally considered to have four sub-cultures: a reporting culture that encourages honest disclosure; a flexible culture that can flatten the hierarchy and grant autonomy to people at the sharp-end; a learning culture that is proactive and competent in drawing smart conclusions; and a just culture that fosters trust and bolsters the other three subcultures while still drawing a line somewhere.

Just Culture is such an important, yet nebulous idea that it warranted a book by Dr. Sidney Dekker, a 737NG first officer and professor of human factors and flight safety at Lund University School of Aviation in Sweden. His book is not about diversity in Queens, but rather “Balancing Safety and Accountability” and how easily our society (or an organization, or the FAA) can shoot itself in the foot when it straddles the line between pragmatic and procedural reactions. Should the JFK controller be punished simply because he did something that is frowned upon? Or should he be punished only if there is something legitimate and valuable to be gained from his termination? I don’t even know if letting someone else speak over the radio is explicitly prohibited in the controller’s book of “Thou Shalt”.

In this instance, a smart and just culture would weigh the pros and cons of going after the controller by asking questions like “what is the informed community saying?” and “how will our decision impact our relationship with our workers?”. Before the pages in his book are even numbered with numbers (it’s on xii), Dr. Dekker says that “Unjust responses to failure…are not about bad performance. They are about bad relationships”.

No good parent would send their kid to his room for doing something that was neither bad nor against what they had told them to do. When I was younger, I was only ever punished for beating up my sister (now I just do it without getting punished). But mom and dad never used my middle name when I forgot to save some money during the week.

So maybe, instead of rationalizing the punishment, we need to reason with reality and develop professional tolerances that encourage cooperation for when the system really demands it. Severely punishing the JFK controller for something more dumb and petty than violent and egregious can leave the brotherhood of controllers bitter and resentful towards the system in which they work.

And who wants to be safe when you’re too busy being bitter and resentful?


P.S. – “Just Culture” was in the cockpit of US1549. Captain Sullenberger was reading it during his trip when he landed in the Hudson. He was given another copy – as well as the key to New York City – by Mayor Bloomberg.

Assuring safety with “the other” SMS

5 02 2010

I’m currently reading a relatively recent advisory circular from the FAA, AC120-92 [PDF], “Introduction to Safety Management Systems for Air Operators”.  It’s for a research project, but I have no shame in admitting that I’d probably be browsing through it even if I didn’t have a grade pushing me along.

A safety management system is the regulatory way of saying to airlines, “Look – your guys’ operations have become so complex and diverse that we’re going to grant airline management some autonomy in the safety department.  Using this framework [plunks a 40-page document on the desk] we want you to establish a safety program that can adapt and evolve with time.  Report to us.  Due soon.  Thanks.”  That’s the quick and dirty of it.

James Reason is just a small mouse in a big world of Swiss Cheese models.

Nick Sabatini, the former associate administrator for aviation safety for the FAA, spoke at IASS (International Aviation Safety Seminar – I know…) in Beijing last fall.  He explained SMS in more eloquent terms as an “evolution of safety” that is “culture-driven, highly measurable, and analytical”

Which is true.  The culture-driven part, especially, as it signals a shift in focus away from a sheltered Orwellian workplace that some airlines have unfortunately adopted to a more natural and approachable environment.  A culture comes to be from common beliefs and values (towards safety, say) that develop organically and authentically.  From that, behavioral norms begin to emerge to the point where behavior that is universally embraced is also behavior universally practiced.  But it’s a gradual process.  (See James Reason’s seminal “Managing the Risks of Organizational Accidents” p. 192 for more.  He made the Swiss Cheese model.)

So an SMS is constructed around four central ideas: safety policy (the commitment from management); safety risk management (identification, analysis, and control of hazards); safety assurance (monitor of effectiveness); and safety promotion (culture).  What caught my attention was something on page seventeen of the AC about safety assurance and how to get the information for proper decisionmaking:

The highlighting is mine and the yellow quote bubble shows that I left a note in the margin.  My note has to do with the fact that, by this definition, safety assurance is still relatively unchanged.  The very safety intelligence that drives the whole SMS can not be fenced in by the bureaucracy and regimen that is consistent with pre-SMS safety philosophy if the whole project hinges on a culture that is dynamic and constantly evolving.

Here, safety assurance essentially takes place in an echo chamber where decision-makers are exposed only to the information the system is designed to share.  Top-down analysis and conclusions may fail to recognize more systemic, yet casual and seldom-reported impediments to safety.  Employee reporting systems are, indeed, effective in collecting information, but they always have and always will amount to a broad channel that feeds from single employees to many in management.  With just the Aviation Safety Reporting System (ASRS) and other structured interactions, valuable insight from people at the sharp-end of the airplane are at risk of being stovepiped into obscurity.

For safety to truly be generative, people with information should not be bound by formal reporting systems.  Greater, broader platforms of communication can elicit productive discussions about a hazard and even shed light on new or potential threats.

This is where a discussion about Enterprise 2.0 and emergent media (that is, media that produces emergent phenomenon) kicks off.  But I’d like to hear your reactions about what I’ve said so far.  Leave comments!