AVIATION SAFETY
LEADERSHIP
Dan Newby
Jinobi Narain
2016 The Outcome-Oriented Academy. All rights reserved.
All images featured in this ebook are stock photos used for illustration purposes only.
www.outcomy.com
Email: info@outcomy.com
DISCLAIMER - Outcomy and its employees expressly disclaims all liability to any person or entity, in
respect of anything done or omitted and the consequences of anything done or omitted, by any
such person or entity in reliance on the contents of this publication.
Contents
Chapters
1. Introduction 2
1
Chapter 1
Introduction
In a recent survey we asked participants how often they have met
aviation professionals who had excellent technical skills but lacked
interpersonal skills. The following is the response from pilots,
maintenance and operations staff, 85% of whom mentioned that
they have very often met such people.
2
You wont see the human factors if you dont have the
eyes to see them.
It is well-known that approximately 70-80% of aviation accidents are due to human
error. In most cases, these errors occur inadvertently and are simply the result of
interactions between various tangible and intangible systems elements. The
tangible elements include airports, airplanes, pilots and mechanics; the intangible
elements, such as language, emotions and trust, are also deeply involved in
systems interactions. Because all aviation organizations are fundamentally driven
by human interactions, the exclusion of these intangible elements is not possible,
and they should be considered with the same importance as the tangible
elements.
3
Chapter 2
Safety Management vs. Safety Leadership
Safety management can sometimes focus on processes,
procedures and checklists in a mechanical routine, but safety
leadership is about checking the checklist, evaluating oneself and
others, and always asking questions such as What has the team
missed? and What is nonstandard here that is important? with
regard to everyone on the team.
4
Creating a positive safety culture
Safety culture is how people behave when no one is watching.
5
Going beyond compliance, towards commitment
to safety
Whereas safety management is more focused on reason and logic, safety
leadership brings in emotions as a key component. Fundamentally, safety
management depends on the emotion of compliance (I will do it because I am
obligated to follow the procedure and because there are negative consequences if
I dont, or I will do it for you because you are my boss and you asked me to),
whereas safety leadership depends on the emotion of commitment (I put my
whole self into my work/actions because I choose tobecause I care).
One does not exclude the other. A person can have a safety management and a
safety leadership mind-set at the same time or can switch back and forth from
moment to moment so as to see differently, ask different questions or take
different actions. Both are essential to generating comprehensive safety.
6
Chapter 3
The Role of Emotions
in Aviation Safety
Transport Canada developed a Dirty Dozen list of 12 common
causes of human errors.
Lack of
4 Stress 8 Awareness
12 Norms
A deeper look at the Dirty Dozen reveals that these unsafe behaviors are the
result of one or more emotions. Emotions are the most overlooked area in
aviation human factors even though they are one of the most powerful domains
for learning and transforming safety behavior. Emotions cause people to take
action, and every decision a person makes has an emotion driving it. However,
very few safety enhancement initiatives have identified and acknowledged the
role of emotions in accidents and safety incidents.
7
What keeps people from taking a stand?
Consider, as an example, a situation in which a
first officer is not able to challenge the captain,
leading to a fatal crash. Typically, this behavior is
labeled as a lack of assertiveness; the human-
factors or CRM training will advise that people
must be assertive in such situations. How can
someone develop the necessary assertive behavior
if he or she is not naturally like that?
Assertiveness means taking a stand for ones
beliefs. What keeps people from taking a stand?
Fear of consequences and lack of self-confidence
are the two main reasons. Think of the possible
emotions that kept the first officer from being
assertive, such as fears related to retribution,
losing face or causing the captain to lose face
(the underlying emotion could be shame, respect
or concern) or doubts (Im unsure of the
outcome because Ive never done this before).
However, there is always an emotion involved at
the root.
8
Understanding emotions as a source of information
There are hundreds of emotions, and learning to understand and
name each of them is the first step toward emotionally intelligent
behavior.
This is a challenge with emotions because people do not see them directly and
can only know which ones are present by interpreting their own feelings or by
interpreting the actions of others. The philosopher Ludwig Wittgenstein pointed
out this inability to define things exactly a century ago, saying, If it is true that
words have meanings, why dont we throw away words and keep just the
meanings? In other words, humans are always living in interpretations rather
than definitions, and it is those interpretations that are most important. Applying
that to the area of emotions means that it is useful for each person to have an
interpretation of the meaning of the 250 or so emotions that he or she can
experience.
The following are the top five emotions chosen by the global aviation community
when we surveyed them to evaluate the role of emotions in aviation safety.
I believe I am smarter than others and as a result am also better than them.
Arrogance My tendency will be to dismiss their ideas and suggestions as coming from an
inferior being.
I will go along with this initiative because I do not have the freedom to
Compliance
decline and the predisposition is to go through the actions.
I believe I know enough to get by and as a result do not put effort into
Complacency
checking or learning.
9
Chapter 4
Learning to Trust Oneself and Others
An organization can benefit enormously by creating a shared
interpretation of trust, by articulating it and by learning to teach it
and use it within the organization. This is one of the biggest missing
skills, no matter what type of organization it is or where in the
world it is.
We at Outcomy did an internal survey for one of the airline operators to find out
why its employees were not reporting incidents as expected, even though the
organization had implemented an online reporting portal and distributed hard-
copy forms for employees to fill out and submit. The top reason that the
participants selected was I dont trust that the management will not use it
against me, which is a common concern in many such organizations.
Trust is a part of every thought and action, yet people continually overlook its
importance and, at times, even its existence. Trust exists in all types of
relationships: Employees must trust their leaders; captains must trust their first
officers; ATCs must trust meteorologists; and so on.
10
Is it possible to develop, maintain and repair trust?
The fundamental problem in many aviation organizations is that they do not have
clear conceptions of what trust is and how it is created, maintained or repaired.
Sometimes, they use words such as reliability or confidence, but at the root,
they are talking about trust. When we asked the leaders in these companies what
trust meant in their organizations, the most common responses were Well, we
dont have a specific definition, but we all know what it is and It is difficult to
put into words, but we all know it when we see it. These are simply ways of
saying We dont know. If these leaders dont know what trust is in a way that
they can clearly articulate, how can they be sure that they are living it? How can
they teach it to new employees so that it becomes (and remains) a value that is
practiced in the company?
11
Comparing the traditional and new interpretations
of trust
Trust has traditionally been thought of as a moral issue. A person who was
trustworthy was thus considered a good person. One who trusted others was
considered open and willing to be vulnerable and thus was also a good person.
Trusting and being trusted were seen as indicating a persons quality. In this
sense, trust was a moral issue; it was about goodness or badness. What is a more
useful way to define trust? One simple, clear way is to think of it as the emotion
that allows people to coordinate actions. Because aviation organizations exist to
produce results by coordinating actions, trust clearly has a central role in making
these organizations work. Another way of thinking about trust is that it is a tool
for gauging the risk of interacting with others (e.g., by accepting promises). In
this revised interpretation of trust, it is a skill that can be learned, practiced and
developed. Being aware of what constitutes trust, choosing to develop the habits
that generate trust and practicing those habits will all result in a higher level of
trust. The emerging trend is to promote a concept called Just Culture, which
can foster fearless reporting. At the core of Just Culture lies the phenomenon of
trust, which allows people to interact with others freely.
12
Safety performance comes from team performance
Teamwork can be thought of as
trust in action, which means that
those on a team understand that
they each have blind spots but
TRUST consider it prudent to take the risk
of trusting one another anyway.
Fundamentally, people believe that
others will fulfil their commitments
in their areas of work.
13
Chapter 5
The Mechanics of Language
and Effective Communication
Although language is spoken of as a domain of learning, this idea is
not about any particular language. Instead, it refers to the
phenomenon of languagethe idea of language. This includes not
just the worlds languages (from Russian to Swahili) but other types
of languages (e.g., mathematics and written music) and activities
that language makes possible (thinking, logic, reasoning,
storytelling, etc.).
14
Clarity in communication for safer operations
Take the example of shift-handover communication which is one of the best-
known safety-critical moments. A request is the tool that is used to get something
that someone else can provide; thus, shift handover can be linguistically seen as
the first-shift operator making a request of the second-shift operator. It is the
first-shift operators responsibility to be sure that the second-shift operator is a
committed listener who is capable of accomplishing the requested task. Once the
first-shift operator is certain the second-shift operator is a committed listener,
the success of the communication becomes a shared responsibility of both people.
The main responsibilities that they are sharing are a quality promise and an
agreement on the clear conditions of satisfaction. From that point, carrying out
the request is the responsibility of the second-shift operator, but the first-shift
operator still has accountability for his or her part until the task is complete.
Sometimes, people believe that they are done once they have made a request,
but linguistically, this is not as effective as it could be.
15
The single biggest problem
in communication is the
illusion it has taken place
- George Bernard Shaw
16
Chapter 6
Learning as the Basis of Safety Leadership
We have worked with hundreds of aviation organizations, some of which had good
safety records and some of which had poor ones. Each of these organizations has a
certain mood, just as people do. Lets look at how the four key moods can
significantly influence safety leadership.
Facticity Possibility Facticity Possibility
Believe that we Believe that we can Believe that we can Believe that we can
cant improve our improve our safety improve our safety improve our safety
safety performance performance performance performance
Resignation
Resentment
Resentment Resignation Our safety
Our safety
Resist
Resist
Organizations with good safety records. Organizations with poor safety records.
Acceptance Enthusiasm
Enthusiasm
Acceptance Our safety Our safety
Our safety records
Accept
Accept
Some of the leading airline operators believe that they have the top SMS rating
and hence that they have the safest operations in the world. A few others take
pride that they have received the Safest Airlines Award and thus believe that
they are good enough. There is no doubt that these organizations have the best
safety records in the industry, but these award-winning airlines still have many
incidents and accidents. The main problem is that these organizations are living
with a mood of either acceptance or resignation, as indicated in the diagram
above, so they tend to develop a degree of resistance to learning and change. The
same barriers to learning are present in organizations with poor safety records
when they have a mood of acceptance or resignation.
17
Dangerous moods influencing safety leadership
Irrespective of an organizations accident history and credibility, its prevailing
mood will greatly influence its safety levels. Acceptance and resignation can have
negative effects on safety leadership. Resentment and enthusiasm encourage
learning; these useful moods can be developed to create a positive safety culture
in the organization. It is the safety leaders responsibility to shift moods and
generate the curiosity and rigor necessary to drive continuous learning and
change.
Everyone always lacks knowledge, and curiosity is the key emotion that allows
people to learn. Requesting knowledge is how people activate learning, whether
that learning is from a person or a repair manual. The world is always changing
and providing new things to learn.
18
Chapter 7
Safety Coaching to Develop a Just Culture
Safety promotion is one of the four pillars of a SMS, and safety-
leadership coaching can be a highly effective approach to
communicating and developing a Just Culture.
19
The 3-step blaming sequence
Expectation
Everyone is constantly imagining what the future will look like.
Often, what people envision is based on history (e.g., Tom is a great
mechanic, and he will carry out this work safely because he has
never made any mistakes) or on others promises (e.g., Tom is a
great mechanic because he says he is aware of all the procedures
and has agreed to follow them), but most of the time, it is based on
what we would like to have happen (e.g., Tom is a great mechanic,
and Im sure that he will follow the procedures and carry out the
work safely). In the latter case, the expectation is that Tom will
know and follow the rules. He may or may not have made that
explicit promise.
Disappointment
Say that Tom makes an error that leads to an incident. The
expectation was not fulfilled (Tom didnt behave in the way I
thought he would). The reality of Toms behavior and the story of
how he was going to behave dont align.
Blame
Because people are strongly attached to their stories, when this
incident happens, they believe the action is wrong and that Tom is
responsible. Their predisposition is to blame Tom. This could involves
saying things like, We thought Tom was aware of the procedures,
and we dont know why he did not follow them, or I cant believe
Tom didnt check that! The biggest idea people miss is that they
usually think they are right and reality is wrong. However, it is the
story that is made up; reality is as it is.
20
Moving from blame to acceptance
If people are not attached to their stories, they will realize their belief that Tom
will always follow procedures is their story and accept that people
unintentionally make errors. This acceptance is the foundation of Just Culture;
from there, solutions such as coaching, systems redesign and process
reengineering can be implemented.
When faced with reckless behavior, the first step is to accept that the person is
reckless because of the way he or she sees the world (at least, as it is understood
from the organizations viewpoint). For example, people who are fearless or who
ignore fear as a warning sign will not see problems that can hurt themselves or
others. This means they do not fit into the necessary system. Instead of punishing
these people, it would be more productive to apply the consequence of change or
leave. As part of safety coaching, coaches can make this a black-and-white choice
for the offender. Safety coaches can also help the offender create a high level of
self-awareness and change the way he or she sees the world through coaching.
Once that person makes a choice and promises new behavior, coaches need to see
it demonstrated to be sure he or she understands what to do. Safety coaches can
build trust by following the offender through small steps to ensure his or her
sincerity, competence and reliability.
21
Chapter 8
Making Effective Safety Declarations
As part of a highly regulated industry, aviation organizations have no choice other
than to follow authorities mandatory regulations. Have you ever thought about
the nature of these aviation regulations? Linguistically, these hard laws are called
declarations. Thus, they begin, resolve or end something (in this case, they set a
standard).
22
Creating a safer future through declarations
A declaration, by nature, has nothing to do with whether something is true or
false. For instance, a judge can declare you guilty of a crime that you did not
commit. His or her declaration doesnt mean that you committed the crime, but it
does begin your time of incarceration. The fact that a decision has been declared
also does not mean that it is good or bad or that it is right or wrong. A declaration
to invest money may result in losing it all. A declaration of war may end with
ones country being destroyed. A declaration of marriage may end in divorce.
23
Chapter 9
Safety Leadership from a
Business Perspective
What airline operators leave unspoken (because the survival of their businesses
depends on earning profit) is that when they say our top priority is safety, they
mean our top priority is safetyas long as it doesnt threaten our profitability.
Although a for-profit corporation can care deeply about serving its customers, it is
by definition an organization that aims to earn profit through its operations so
that it can survive. A for-profit corporation doesnt have a choice; it must earn
profits if it is to continue to exist. An airline pays attention to safety because, if
there is a perception that its safety standards are low (i.e., mistrust), fewer
people will coordinate actions and will no longer fly with that company, which
endangers its profitability and survival.
24
Quality and productivity through safety leadership
Being a safety leader means being responsible for declaring
enhanced safety levels and enrolling followers to support your
vision.
It also means that actively engaging your whole being in your safety leadership
(i.e., showing commitment) and not just talking about it. Any follower who
contributes to this vision adds value, and those who do not contribute add waste.
Safety is a value that translates into financial benefits in many ways.
25
Chapter 10
The ACTIVE Safety ACTIVE
Coaching Framework
SAFETY
CULTURE
A Awareness
Overcoming the barriers to
Learning
C Communication
Body. emotions and language as
sources of information
Safety Coaching vs.
T
Trust Safety Training
An emotion that lets us
coordinate action The ACTIVE safety-coaching
I
framework is designed to develop
V
The focus of safety coaching is on
Vision creating a context in which
employees will inevitably learn
Creating a safer future through
declarations about themselves and the
particular ways that they behave in
E
each context. This is different
Engagement from safety training, in which
From compliance to commitment employees receive information
to engage the whole person that is only about safety.
26
TAKE THIS LEARNING FORWARD
Aviation Safety Leadership Training and Coaching
Dan is heading the safety and risk leadership practice at Outcomy and is the lead
facilitator and coach working with leaders and organizations worldwide. His
background in education, 16 years as an ontological coach and 10 years delivering
organizational training and coaching have prepared him for this work. His roles
have included working internationally as COO and CEO of Newfield Network, USA,
considered one of the premier coaching schools globally where he was also a
senior course leader for 8 years. Dan is a Professional Certified Coach (PCC) by
the International Coach Federation (ICF). Dan has taught, presented and coached
with leaders and organizations in the USA, Canada, Europe, South Africa,
Singapore, India, Pakistan, Latin America and Jamaica.
28
A BEHAVIORAL APPROACH TO AVIATION SAFETY LEADERSHIP
www.outcomy.com
Email: info@outcomy.com