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The deficiencies found in the report were in Just Culture and Reporting Culture. The five Key Elements of Safety Culture are: 1) Informed Culture- the organiz
by hammock 3y ago
The deficiencies found in the report were in Just Culture and Reporting Culture.
The five Key Elements of Safety Culture are:
1) Informed Culture- the organization collects and analyses relevant data, and actively disseminates safety information.
2) Reporting Culture- cultivating an atmosphere where people have confidence to report safety concerns without fear of blame. Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting.
3) Learning Culture- an organization is able to learn from its mistakes and make changes. It will also ensure that people understand the SMS processes at a personal level.
4) Just Culture- errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
5) Flexible Culture- the organization and the people in it are capable of adapting effectively to changing demands.
Sources:
https://www.faa.gov/newsroom/Sec103_ExpertPanelReview_Report_Final.pdf https://www.faa.gov/newsroom/Sec103_ExpertPanelReview_Report...
https://www.airsafety.aero/safety-information-and-reporting/safety-management-systems/safety-culture https://www.airsafety.aero/safety-information-and-reporting/...
- burnerburnson 3y ago> errors and unsafe acts will not be punished if the error was unintentional. No sane organization would ever implement this. If someone repeatedly makes mistakes, they're going to get fired even if the mistakes are unintentional. Anything else is going to cause more safety issues in the long-term as inadequate employees are allowed to proliferate.
- zettabomb 3y agoEvery sane organization implements this. Failure to do so leads to fear of reporting mistakes, and you get Boeing. This isn't news.
- jjk166 3y agoIf it's possible for an employee to unintentionally make the same mistake twice, that's purely management's failure. It's impossible to make systems completely fool proof, but once you know of a specific deficiency in your process you fix it. If you've corrected the issue, it should take deliberate effort for someone to do it again. An organization that knows its processes are deficient but makes no changes and expects a different result is insane.
- deleted 3y ago[deleted]
- byteknight 3y agoFurthering the insinuation that everyone has the right to work every job. Sometimes people suck at their job.
- error_logic 3y agoAs your sibling comments mentioned, there's a difference between giving a chance for someone to learn from a single mistake without punishment, and allowing them to make the same mistake twice without taking matters out of their hands after. If it's a really critical role, the training will have realistic enough simulation for them to make countless mistakes before they leave the training environment. Then you can assess their level of risk safely.
- hinkley 3y agoThis whole thread is missing the fact that the NTSB had a theory that transparency leads to safer airplanes, they tried it, and it works. People hesitate to self-report when it comes with punishment (fines, demotions, or just loss of face among peers). You need a formal “safe space” where early reporting is rewarded and late reporting is discouraged. Safety is a lot about trust, and there is more than one kind of trust. At a minimum: are you capable of doing this thing I need you to do? Will you do this thing I need you to do?
- zettabomb 3y agoIt's not just the NTSB, it's part of things like the Toyota Production System. There's ample evidence to show both that punishment discourages safety and that lack of punishment encourages safety, across multiple industries.
- ethanbond 3y agoBut but but what about my intuition and gotcha questions about how this could never work in practice?
- deleted 3y ago[deleted]
- deleted 3y ago[deleted]
- icegreentea2 3y agoJust culture doesn't prevent you from firing someone who makes repeated mistakes. In fact, Just Culture in itself provides the justification for this. As the next line says "However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action". A person who repeated makes mistakes is an unjustifiable risk.
- hinkley 3y agoWhen a punishment is applied with more deliberation, it can also be more severe.
- wolverine876 3y agoWhy is severity desirable? Or if it's not desirable, so what?
- sokoloff 3y agoSeverity is desirable iff it's justified. I wouldn't ever sign off on a policy that says "you'll be fired for a single mistake" (that would be a severity of punishment out of proportion to the risk/underperformance). But a policy that never provided for the possibility of termination (insufficient maximum severity) is also not desirable.
- wolverine876 3y ago> Severity is desirable iff it's justified. It's necessary if it's (necessary & efficient & justified); it's never desirable IMHO. Doing severe things because they are justified is just acting out on a desire or drive - internal anger - but now we can 'justify' the target and feel ok about it. Lynch mobs think they are justified.
- sokoloff 3y agoDesigning severe things to be included as part of a process is a desirable property of that system if the severe thing is sometimes required. No one is designing a formal system that includes lunch mobs. But a formal system of repercussions for employee behavior that does not include firing is an incomplete system. It’s not that firing itself is ever desirable, but rather that its inclusion in a disciplinary progression is desirable.
- buttercraft 3y agoThat's quite a leap from "unintentional" to "repeatedly."
- wolverine876 3y agoNot at all: Systemic problems will result in repeated errors until the system is changed.
- applied_heat 3y agoYou can really dumb it down to why didn’t you follow the checklist? If someone makes the same mistake after being corrected three times and the proper procedures exist for the worker to follow then the safety culture provides the structure and justification for their dismissal
- buildsjets 3y agoNo, you really need to smarten it up, and start off by making sure that your checklist is correct. Is it the correct checklist for the airplane model that you are building? Are all the right items on the checklist? Are they being done in the correct order? Do you have the correct validation/verification steps in your checklist? Does your checklist include all the parts that will need to be replaced? If the mechanic finds a quality issue while working the checklist and a job needs to be re-done, which checklists then need to be re-done? What other jobs are impacted by the rework? All indications here (from the NTSB prelim and the widely reported whistleblower account) are that during rework for a minor manufacturing discrepancy, the mechanics on the shop floor followed bad manufacturing planning / engineering instructions to-the-letter, then the ball was dropped in error handling when the engineering instructions did not match the airplane configuration, because Boeing was using two different systems of record for error handling that did not communicate with each other except though manual coordination. That's not the fault of the front-line assembly worker not following a checklist.
- applied_heat 3y agoI agree with you. If the systems/procedures/checklists are bad it is not the fault of a front line worker. I thought I was replying more to a parent comment addressing the inability to people go who repeatedly make mistakes, which is acceptable unless they are not following procedures.
- empath-nirvana 3y agoThis is just blameless post mortems and many, many many places implement this. There are always going to be some level of "inadequate" employees, and also perfectly adequate employees that sometimes make mistakes in any organization and if your organization requires that no employees ever make mistakes in order to operate safely, then you have serious problems. The purpose of a statement like that is that you don't just have a post-mortem that is like: "Our company went off the internet because an employee had a typo in a host name. We fired the employee and the problem is solved." When in reality the problem is that you had a system that allowed a typo to go all the way into production.
- error_logic 3y agoIt's like that story of the pilot who, after his refueling technician almost caused a crash by using the wrong fuel, insisted that he always have that technician because they'd never make that mistake again.
- s1artibartfast 3y agothe question is what do you do with the technician after the 2nd mistake. that is to say, When does this logic break down?
- lucianbr 3y agoIf you implemented some changes so the mistake is caught before disastrous consequences, you're already doing better. Well enough to let the 2nd one slide. Even the 3rd. After that, action seems reasonable. It's no longer a mistake, it's a pattern of faulty behavior.
- s1artibartfast 3y agoThat is a big IF. At some point it comes down to the error type, and if it is a reasonable/honest mistake. The situation is very different if the fuel cans are hard to distinguish vs if the tech is lazy and falsifying their checklist. Underlying any safety culture is a one of integrity. No safety culture can tolerate a culture of apathy and indifference.
- beaeglebeached 3y ago[flagged]
- gklitz 3y agoWhat a reductive attitude. If your planes fall from the sky because a single employee is negligent. The ones to blame isn’t the worker, the union or the state. It’s your business that has key deficiencies in implementing safety. Your QC process has to be able to catch these things. It’s not like you can avoid any reliability in your process and just lean back and be like “don’t worry bro, it’ll fly, we hired all non-union workers”
- beaeglebeached 3y agoWhat a reductive attitude. Nah not just one negligent worker. Many, including QC staff.
- hinkley 3y agoThis also sounds like someone in the New Boeing management chain. A lot of these culture problems were already evident during the 787 program, which is when MD’s mismanagement started to fester. And when the hardon for union busting first came to my attention.
- ethbr1 3y ago> The ones to blame isn’t the worker, the union or the state. It’s your business that has key deficiencies in implementing safety. I don't think you're charitably reading parent. Sometimes, the employee is the problem. And sometimes, union contracts preclude changing processes (or make change unnecessarily burdensome) to improve outcomes. Introducing another party into agreements doesn't come free. I'm as pro-union as anyone around here... but it is another level of bureaucracy. And sometimes, protecting "our people" can include not letting go people who should be let go (e.g. decreasing headcount in assembly to hire more professional QA people). That said, solutions do need to come from all levels, and I think unions do provide a necessary counter-pressure to management deciding only employees need to bear the brunt of change.
- dclowd9901 3y agoI think the wording is clumsy, but this is analogous no-blame processes. The wording is just accounting for the possibility of wontonly malicious or recklessly negligent work quality. Think someone either sabotaging the product, or showing up to work very high or drunk.
- inglor_cz 3y agoThis. A mistake like "accidentally turning the machine off when it shouldn't be" is a fixable problem. If someone has attitude like "fuck the checklist, I know better", it is not really a mistake, and that person should be rightfully fired or at least moved to a position where they cannot do any harm.
- ClumsyPilot 3y agoWho do you think came up with this rule, bleeding heart liberals’? Stop and think for a second, why does that rule exist? You described a fantasy world, in the real world everyone makes mistakes, and if the mistakes are punished, then there are no mistakes because no one reports them. That is until the mistake is so catastrophic, it cannot be covered up- that’s how you get Chernobyl or Boeing max
- shiroiushi 3y agoBoeing max (if you mean the crashes caused by MCAS) wasn't due to a "mistake" not being reported, it was deliberate and intentional on the part of company management. The system was designed badly and without redundancy, and without any information available to the pilots about its very existence, specifically because management wanted it that way. It wasn't caused by some kind of accident.
- ThrowawayTestr 3y agoI once destroyed $10k worth of aerospace equipment. I admitted it immediately and my only reprimand was that my boss asked me if I learned my lesson. (I did)
- Log_out_ 3y agoOnce destroyed a industrial manufacturing site with a unfinished robot program that ran because I allowed myself to be distracted mid alterations.
- wolverine876 3y agoAnd what happened?
- inglor_cz 3y agoIdeally, as a result of the post-mortem, the same mistake shouldn't even be repeatable, because mechanisms should be introduced to prevent it. And if someone keeps making new original mistakes, revealing vulnerabilities in your processes, I would say that it is a very valuable employee, a lucky pen-tester of sorts.
- idontpost 3y ago[dead]
- deleted 3y ago[deleted]
- WheatMillington 3y agoWowwww never become a manager please.
- ethbr1 3y agoI thought this was critical: >> It also noted that employees do not understand how to use the different reporting systems and which reporting system to use and when. As was noted by the purported insider, re: multiple overlapping systems of record/not-record, Boeing's actual processes themselves are badly in need of overhaul. This feel like a clear example of where top-down + bottom-up independent read-back verification would have been useful. I.e. management decides they're going to create Safety Process X using Systems A, B, and C. They do so, then circulate training (top-down). THEN you conduct independent interviews with employees at the bottom, to measure whether the new processes are understood at that level (bottom-up). If results aren't satisfactory, then add additional training or reengineer the processes. Too often, it seems like this shit gets done at the VP PowerPoint level, and ground reality diverges without anyone noticing. The map is not the world: interviews with a representative random sampling aren't hard.
- lenerdenator 3y agoI'd say Learning Culture is also a problem. Boeing has made numerous missteps in the last 15 years after being the world leader in airliners for around half a century. This only happens when knowledge about how to make a safe product is purposefully discarded and attempts to bring that knowledge back are intentionally ignored. In Boeing's case, it's due to desires for increased profits. They are unwilling to learn these lessons because it costs money that _may_ be there at quarter's end.
- joe_the_user 3y agoI'd note that financial markets driven reorganizations are antithetical to elements 1-4 and this explains how Boeing managed to have a culture of safety but lose it (it's often put as MD management took but an article a bit back showed that this was part of the Boeing CEO seeing the financial writing on the wall). Uh, and that happened "under the watchful eyes" of the FAA. The opposite of 1-4 could be described as the "culture of lies, ignorance and fear". Fear is a good strategy for getting people working hard (if not always well) and lies make fear universal. Compartmentalizing information is needed to allow more and more functions to be subcontracted. If the company is extracting maximum value from it's assets this year, it has no incentive to report problems that will only appear in the future - by the time the future rolls around, the share holders have their and the shell of the remaining company can be tossed away. etc. Also, another HN commentator mentioned how eliminating a culture of lies and retaliation is once it's in place. There's never a guarantee that those revealing a problem won't be punished once regulators turn their backs. And 5 is only useful once 1-4 are in place. Otherwise, it's a culture of flexibly hiding your shit in different places. Edit: This article was on HN a while back. https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merger-led-to-the-737-max-crisis https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merg... Key quote: These decisions, made by Boeing CEO Phil Condit, were made with a close eye on the company’s bottom line ahead of a hotly anticipated commercial-jet boom. An ambitious program of cost-cutting, outsourcing, and digitalization had already begun.
- euroderf 3y ago>> 1) Informed Culture >> 2) Reporting Culture >> 3) Learning Culture >> 4) Just Culture > > I'd note that financial markets driven reorganizations are antithetical to elements 1-4 If this idea could be explored in depth, and more-or-less codified as received wisdom about market players, it would be a great contribution to management "science" and economics. My 0,02€.
- crazytony 3y agoI'm really at a loss on this news. All the employees at airlines in the US I know of have this drilled into them on a regular basis and it's just taken for granted that you report incidents when they happen (even when someone falls: report it!) and the incident will get investigated. It just confounds me (but explains a lot) that the manufacturer of the aircraft the airlines operate does not share a similar safety culture given that they are in a similar ecosystem (airlines report issues to the manufacturer and the FAA/NTSB all the time)
- Zigurd 3y agoAlignment of incentives. Airlines have fewer, smaller conflicts of alignment. Boeing is in a hurry to cash in on huge demand for single-aisle passenger planes before A320/1 or a stretch A220 fill that demand. It gets worse: The longer expansion of 737MAX production is delayed, the less demand. It doesn't just expire, it declines over time. Every sale delayed is also maintenance income delayed. On top of that, Spirit Aerosystems was spun off so Boeing could demand higher production and lower prices, and fragment their assembly line workforce. In this environment, when management has been hostile to their workers' unions, how are workers going to feel safe raising a red flag over "minor" production issues? You can't train for correct behavior when the incentives are so far out of alignment.