International Helicopter Safety Team Safety Management System Toolkit

EXPECTED
Normal Behaviour
“I did my job the way I’m supposed
to, according to all rules and
good practices.”
Intervention
“I identified unsafe acts/conditions,
stopped work and made or
suggested improvements.”
EXEMPLARY
Creating a More Effective
Work Environment
“I helped us understand and improve
our work environment.”
Excellent Planning &
Risk Management
“I avoided human error and creation
of situations that lead to violations.”
Effective Sharing of
Lessons Learned
“I helped others learn from failures
and successes.”
Other
“I did something exceptional that had
a desirable outcome but does not fit
the previous descriptions.”
JUST CULTURE
The Human Error & Violation Decision Flowchart
Start Here
Behaviour At or
Above Expectation:
Identify action,
performance or
behaviour that deserves
recognition or reward.
Level of
severity of
event or
action to
be taken.
Action or
behaviour to
which you want to
apply appropriate
consequences.
COLOR LEGEND
Reward
Behaviour Below
Expectation:
Identify all the actions
and choose the
right classification.
Coaching
Formal Discipline
HUMAN ERROR
Slips and Lapses
“Oops”
Mistakes
“I thought I did the right thing.”
VIOLATION
Unintended
“I was not aware.”
“I did not understand.”
Situational
“I cannot get the job done if I
follow the rules, but I did the
job anyway.”
Organisational Optimising
“It was better for the company
to do it that way.”
Personal Optimising
“It suited me better to do it
that way.”
Reckless
“I did not think or care about
the consequences.”
Routine
“Does this
happen a lot?”
Routine
“Would others
do it
that way?”
and/or
“Does this
person have
a history of
violating.”
Was there a
behaviour
below
expectations?
YES
Did the Person’s
actions deviate
From what they
intended!
ERRORS
NO
Did the person
make an Incorrect
decision or was
their work plan
inadequate?
NO
Did the person
Violate because
they did not understand
or were
unaware of the
rule?
0GANISATIONAL ISSUES
NO
Did the person
violating believe
the job could not
be done if they
followed the procedures?
NO
Did the person
violating think it
was better for or
the company to do
it that way, or,
where they trying
to please the boss?
NO
Did the person
violating think it
was better for
them personally to
do it that way?
PERSONAL ISSUES
NO
Did the person
violating mean to
do what they did
and did not think
or care about the
consequences?
Routine
YES YES YES YES YES YES YES
Slip or Lapse
Routine Error
- same errors by
different people
Mistake
If this happened before.
Routine Error
- personal history
of errors
Unintentional
Situational
Violation
If others do It the same way.
Routine Violation
- same violations
by different people
Organisational
Optimising Violation
Personal
Optimising
Routine Violation
- personaI history
of violations
Reckless
Violation
If this person has a history
of personal violations.
OUTSTANDING
BEHAVIOUR
NORMAL
BEHAVIOUR
UNINTENDED
VIOLATION
SITUATIONAL
VIOLATION
ROUTINE
VIOLATION
OPTIMISING
VIOLATION
PERSONAL
OPTIMISING
VIOLATION
Reward
CONSEQUENCES FOR THE INDIVIDUAL/TEAM
Should receive encouragement and recognition for good working practices from supervisors and higher
management. With contractors, also praise contractor management.
None, the action was an error - should receive training to raise awareness of correct practice/procedure
or to develop skill.
Shall receive coaching on the need to speak-up when rules cannot be followed. Investigation to
understand how this situation was created and why work had continued.
Whole team shall receive coaching on not allowing rules to be broken and learning how to
intervene. Team should use the Managing Rule Breaking process to assess the hazards, redefine
procedures and ensure future compliance.
If the violation was to improve performance or please the supervisor then they shall receive coaching or minor
formal discipline. Should also receive coaching in how to challenge management about poor procedures.
If the violation was for personal gain there shall be formal discipline. There should be anonymous
publication of the violation and its consequences for workers and managers.
Reward
CONSQUENCES FOR THEIR MANAGERS IF SUPERVISON WAS “INEFFECTIVE"
Should provide praise to team and receive recognition from own supervisor if whole team is
working this way.
Shall be an investigation to establish why the poor quality of procedures and training was not recognised
as an issue before. Coaching to ensure that correct procedures are provided and understood in he future.
Should receive coaching on how to use the Managing Rule Breaking tool with team to identify other situational
problems that will lead to violations. Minor discipline should be received for allowing this situation to exist.
Manager’s performance appraisal should be affected for not demonstrating commitment to rule
compliance and making the effort to establish if the rule is necessary and where appropriate removing
or altering the rule. Shall receive coaching on how to establish compliance for Managing Rule Breaking.
Manager’s performance appraisal shall be affected and formal discipline considered for allowing
team to believe rule breaking is desirable.
Coaching shall be provided for managers on how to set standards of acceptable behavior.
RECKLESS
VIOLATION
Should be final warning or immediate removal for wilful and reckless violations.
Courtesy of Patrick Hudson, PhD, Leiden University - CHC 2009 Safety Summit
One-on-one coaching of manager should be provided in how to recognise and deal with such behaviour
earlier. Review of selection and training processes to see why this was not identified before.
SMS Toolkit 89