An Argument for Introducing ‘Risk Culture’ as a new component of ‘Safety Culture’
BACKGROUND – Setting the Context
The ICAO Safety Management Manual (Doc 9859) and many other guidance materials published by the regulatory authorities around the world refer to models and frameworks such as ‘4 Components of Safety Culture’ (Reason, 1997), Ron Westrum (three categories of organisation culture), ‘Culture Ladder’ (Hudson, 2001) and ‘Just Culture’ model (Dave Marx – Outcome Engenuity, 2015). As a result, the stakeholders in aviation have so far considered only these perspectives in terms of measuring, assessing and developing their safety culture. While these models are valid and – when effectively applied – can have significant impact on organisations’ safety performance, it can be argued that these models seem to be very much focused on collection of past event data, which is inevitably backward looking and they do not specifically aim to explore how risk is perceived and managed at different levels in organisations. For example, what/how risk decisions are made by front line operators and if senior management is presented with the same risks accepted by front line staff, would they take the same/similar decisions? In other words, have different groups in different levels in organisations more risk averse or more risk taking attitude than each other? If so, what does it mean from a safety perspective as well as for the overall business? It can be argued that these kinds of questions are not addressed by the existing safety culture frameworks.
‘Risk Culture’ – on the other hand – has been studied and recognised as an important part of organisational culture, in other risk oriented industries such as financial institutions as well as some safety critical industries. Additionally the role of ‘risk culture’ in overall risk management process is recognised within the ISO 31000:2009 ‘Risk Management – Principles & Guidelines’, which is not a certification standard but used as a guideline by many organisations. The main idea of this research derives from the ‘Risk Culture’ guidance material produced by the Institute of Risk Management (IRM, a UK based non-profit organisation), in order to support the implementation of ISO 31000:2009. The term ‘Risk Culture’ is not well known or regularly discussed by airline and/or MRO industry safety practitioners, but it has the potential for integration within the existing ‘Safety Culture’ models currently applied in the commercial air transport industry. Investigating how risk is perceived and managed across the organisations (in different disciplines/departments i.e. flight operations, engineering etc.) and understanding some of the common themes on what/how risk decisions are made, will help to develop a ‘Risk Culture’ assessment tool.
The idea of introducing ‘Risk Culture’ as a new component of ‘Safety Culture’ has links with a number of previously mentioned models. For example clarification between ‘Acceptable’ & ‘Unacceptable’ risks (however subjective and difficult it may be) can enable a proactive application of ‘Just Culture’ policy. Because collecting data on ‘accepted vs rejected risks’ may give opportunity to identify any potential ‘excessive risk taking’ by front line operators so that risks unacceptable to the management can be clarified/addressed and such behaviours can be hopefully avoided before an actual incident occurs. Otherwise, those who accept some level of risk in their operational environment may not realise that their actions are not acceptable to the management and they continue ‘getting away with it’ until it ends up with a bad outcome and then this will likely lead to a disciplinary action. Subsequently the management who may end up taking disciplinary action also has to take the difficult decisions such as whether to try to justify the decision taken by communicating with the whole population or let the rumours go around in the organisation (‘who took what decision’ and ‘whether the disciplinary action was justified or not’ etc.) The impact of ‘taking disciplinary action’ on particularly reporting culture (mature reporting i.e. reporting of own mistakes) is most likely in many organisations. The concept of ‘Risk Culture’ may proactively identify such issues and address them by organisational development and learning.
Also, it is inevitable that the question of ‘how much risk is excessive’ will always be subjective just like the non-existing line between ‘risk taking and negligent behaviour’ (Dave Marx Just Culture model). Nevertheless if the front line operators are taking risks based on their perception and certain circumstances, and these are not acceptable to the line or senior managers, then there will be opportunity to address underlying causal factors (systemic issues) and/or giving clear messages about the unacceptable risks. Furthermore in some countries or organisations, the degree of ‘can-do attitude’ can be a driving force for excessive risk taking because people genuinely care about their employer and they believe that they are saving the day (i.e. releasing or accepting an aircraft with a ‘not clear cut’ defect in order to avoid huge cost driven by a technical delay.)
It can be argued that the ‘Risk Culture’ argument also has link with Hollnagel’s Safety I and Safety II concept. The data on ‘ACCEPTED’ and ‘REJECTED’ risks collected so far have examples of both perspectives. While ‘Rejected risks’ are more relevant examples of Safety and the data on ‘Accepted Risks’ can have both Safety I and Safety II examples because in some cases certain risks are accepted only after specific mitigation measures were applied. So the data collected by this methodology may also enable identification of ‘practical mitigation strategies’ applied by professionals so that they can be shared across the organisation/industry.
THE MAIN REASONING
It is believed that the idea of introducing the ‘Risk Culture’ as a new component of ‘Safety Culture’ may bring a more ‘proactive’ approach because the existing frameworks / models on safety culture focus mainly on reporting occurrences/incidents (in some cases hazard reporting but not accepted or rejected risks) which is rather backward looking and does not give much focus on how people deal with uncertainties and make risk decisions in operational and organisational context.
THE AIM OF THE RESEARCH
The potential gap in risk perception amongst operational staff as well as between operational staff and their (line and senior) managers is a supposition accepted by many professionals. Nevertheless the evidence collected from different organisations may prove or disprove this hypothesis but more importantly, from a pragmatic point of view, the main question to consider is:
- Are all risks taken by operational staff during day to day operation acceptable to their line and senior managers who may be ultimately liable for such accepted risks from legal point of view?
The initial phase of the study will aim to collect data across the industry. The analysis of data from the wider population will enable to design case studies with participating organisations (airlines and maintenance organisations). This will give opportunities for organisational development and learning such as:
- If line managers certainly disagree about accepted and/or rejected risks (expressed by front line operators), then they can communicate/clarify management’s view on these cases to achieve a proactive ‘Just Culture’ implementation. i.e. they much better understand what is not going to be tolerated. Because, once a punitive action is taken even as part of ‘Just Culture’ policy, its impact on ‘Reporting Culture’ is very difficult to mitigate.
- Also any potential disagreement on tolerability of certain risks amongst line managers may require certain risks to be escalated. i.e. escalating certain safety risks to enterprise risk level so that senior management are aware of them. (Ref. ISO 31000 Risk Consultation & Communication)
Ultimately the lessons learned from these case studies may enable to develop a model/framework to assess ‘Risk Culture’ in organisations operating in commercial air transport industry.