1. Improving our Safety Culture

2. What is a Safety Culture?
Reporting Culture
Flexible Culture
Learning Culture
Just Culture
Informed Culture
Reporting Culture - Organizational climate where people readily report problems and errors.
Just Culture - An atmosphere of trust where people are encouraged and rewarded for providing safety-related information.
Flexible Culture - The organization is able to reconfigure itself in the face of high tempo operations or certain kinds of danger – often shifting from the conventional hierarchical organization to a flat-level organization.
Learning Culture - The willingness and competence to draw the right conclusions from safety information.
Informed Culture - System mangers and operators have current knowledge about the human, technical, organizational, and environmental factors that determine system safety.
Source – Professor James Reason 2

3. It’s a Journey

4. Safety Culture Evolution
GENERATIVE
Safety is how we do business around here
Chronically Aware
Increasing Awareness
PROACTIVE
Anticipating and preventing problems before they occur
CALCULATIVE
We have systems in place to manage all hazards
Increasing Trust
REACTIVE
Safety is important, we do a lot every time we have an accident
*Adapted from Safeskies 2001, “Aviation Safety Culture”, Patrick Hudson, Centre for Safety Science, Leiden University
PATHOLOGICAL
Who cares as long as we’re not caught
Chronically Complacent 4

5. Why ATSAP? Error v. Risk Even the best people make mistakes
Errors are consequences rather than causes
Use errors to understand ‘why’ not ‘what’ or ‘who’
ATSAP will help us move operations in the NAS away from Error Management towards Risk Management

6. 17,000 Safety Specialists What ATSAP is: What ATSAP is not:
ATSAP is a front-line, pro-active, corrective action-based safety program.
ATSAP requires an equal commitment and understanding from the ATO, AOV and NATCA.
What ATSAP is not:
It is not an immunity program.
It does not apply to deliberate acts.
It does not apply to gross negligence.
It does not apply to criminal acts.

7. ATSAP PURPOSE The primary purpose of ATSAP is to
identify safety events and implement skill
enhancement and system corrective action
to reduce the opportunity for safety to be
compromised.

8. ATSAP To Date Enroute -- 59% Commencement Date: July, 2008
Eligible Facilities: 75
Eligible Reporters: 4,700+
Reports Received: 2,900+
Known Events %
Unknown Events %
Other %
Percentage of reports by Facilities:
Enroute %
Terminal %
System Ops <1%

9. ATSAP Positives Opens Lines of Communication
Frequency Problem identification
Identification of Time-Based Metering issues
Radar/Automation Display issues (Hand offs, Flight plan processing issues, radar mapping)
Identification of insufficient training (LOA/equipment)
Problem w/AWOS altimeter settings – auto updating
Reduction in non-productive Skill Enhancement training

10. Going Forward…
Remember what I said at the beginning of this program about airlines with the most successful ASAP programs are the ones whose upper management support the programs by instituting the changes dictated by the information?
If we are serious about air safety and about reducing the number of accidents and serious incidents going forward to the Next Generation Air Transportation System, then the FAA MUST do two things.
It must incorporate a major stakeholder of the NAS into its Voluntary Safety Program network by establishing ASAP for ATC.
Secondly, as we move towards VASIS and a growing national database, at the highest levels within the Administration, the FAA must derive ways to more responsibly enact changes that are dictated by the data. As the pool of information grows, so does the culpability by all the stakeholders, but most importantly, the regulator.
What it boils down to is this: If we have vital information that could have prevented the LAS encounter, the ORD near collision and the LEX accident we must collect it and find the ways to act on it.
This is the challenge to the industry

11. Measure of Success “ My pledge to you is that our success will not
be measured by numbers of operational errors
and deviations – instead it will be the number
and nature of safety issues we identify and
jointly resolve. Whether you are a manager or a
bargaining unit member, I ask you to join me in
this endeavor.”
Hank Krakowski, COO
Air Traffic Organization