The Role of Discipline in Building an Effective Safety Culture

The Role of Discipline in Building an Effective Safety Culture

By Jacqueline Booth-Bourdeau

May 2000

Transport Canada recently played host to the 14th annual symposium on Human Factors in Aviation Maintenance. The conference, a joint initiative with the United Kingdom Civil Aviation Authority and the Federal Aviation Administration, attracted 400 people from 28 different countries. While there is nothing unusual about an aviation maintenance conference; it is unique that all of these people came together to focus on one issue: Safety Management in Aviation Maintenance. Such is the growing recognition of the importance of the human contribution to aviation incidents and accidents.

Building an effective safety culture
Over the course of three days, delegates heard 39 different speakers talk about such varied topics as human performance, fatigue management, and the establishment of safety management systems. At the root of all of these issues, and the key to successful error mitigation, is management's commitment to safety - first and foremost, and the commitment of the individual to error prevention. Having said this, there was a constant refrain from each speaker suggesting that this can only be achieved within an environment of mutual trust. In effect, a company's "safety" culture will only be effective if it is just and based on the fundamental tenets of fairness, respect, and trust.

The Swiss philosopher Rousseau once said: "It is too difficult to think nobly when one thinks only of earning a living." While Rousseau may have been talking about the basics of life, his suggestion is as appropriate today as it was in the 18th century. If we extend this logic to the aviation maintenance environment and look at the issues involved in managing safety in a proactive way, we have to ask the question: What happens when a mistake is made and the error is reported? What happens when workers suggest that they are too fatigued to work another shift? Does the company culture support "noble" disclosures of this kind in a non-punitive way, or does the offender lose his or her livelihood?

Honest mistakes or reckless behavior?
David Marx, in his research into discipline, has suggested that "...a line must be drawn where one leaves mere human error behind and enters more culpable and blameworthy behavior." If the speakers at our recent symposium were any indication, it would appear that this notion is becoming more widely accepted within the industry. At Air Nova, for example, the Error Reduction Management Program Policy states: "Under the terms of this policy, disciplinary action will not be taken against an employee for a technical human error. Discipline would be permissible when: a) The employee's actions involved violations of health and safety policies; or b) The employee has been reckless, as determined by the Culpability Review Board that the employee consciously disregarded increased risk."

Air Canada utilizes a similar process in its corrective action process. In the case of an accident/incident investigation, emphasis is placed on the "human factors" part of the issue. Under this system, honest mistakes are not subject to disciplinary action; intervention tools such as training, coaching, and participation in the development of preventative measures are used instead. The speaker explained that in certain cases this has involved having the person write an article for the company newsletter, highlighting the mistake and the corrective action taken to prevent a reoccurrence. Of course, strict criteria have been established for determining culpability where the individual is thought to have been reckless, willful or unwilling to cooperate in an investigation.

Keeping score
Taking this one step further, Singapore International Airlines Engineering have developed a schedule of punitive actions and a schedule of demerit points. Basically, this involves assigning a point value for different levels of negligent behavior. For example, negligent behavior that could affect safety is assigned a demerit value of eight, while a deviation from standard or good engineering practices, such as failing to wipe away excess grease after servicing, represents a point toll of one. Administrative actions are based on the number of demerit points acquired by the individual. Twelve or more demerit points are sufficient to warrant an inquiry that could lead to privilege suspension and a job reassignment. Lesser point accumulations may merit staff counseling or a letter of caution.

These approaches demonstrate that there are alternatives to the "blame, shame, and fire" approach to discipline in the workplace. The post incident/accident investigative process serves a vital role in ensuring that there is a perception of justness in the workplace. Moreover, it helps provide vital information that might prevent another more serious outcome.

From the regulatory perspective there are lessons to be learned as well. Perhaps, an error occurred because there was a misinterpretation of the aviation regulations; there was no willful intent, merely a misunderstanding. In cases like this, we have to review our own rule-making practices to ensure that we take the human factor into account. In other instances, it may be that we can help educate and inform through guidance material and other publications. Or, as our conference delegates will attest, through initiatives like the Human Factors in Aviation Maintenance Symposium that allow people to learn through the sharing of experience and knowledge.