The art of measuring nothing: The paradox of measuring safety in a changing civil aviation industry using traditional safety metrics

Measuring safety as an outcome variable within the ultra-safe civil aviation industry during periods of deliberate organizational change is a difficult, and often fruitless, task. Anticipating eroding safety processes, based on measuring nothing happening over time, does not adequately capture the true state of an evolving safe system, and this is particularly relevant for leaders and managers in a civil aviation industry responsible for maintaining and improving ultra-safe performance while simultaneously managing demanding strategic business goals. In this paper, I will look at the difficulties of measuring safety as an outcome measure in high reliability organizations (HROs) using the traditional measures of incident and accident reporting during periods of deliberate organizational change inspired by the desults from a three-year longitudinal case study of the Norwegian Air Navigation Services provider - Avinor. I will first review the current safety literature relating to Safety Management Systems (SMSs) used in the civil aviation industry. I will then propose a more holistic model that shifts the focus from the traditional safety monitoring mechanisms of risk analysis and trial and error learning, to the natural interactivity within socio-technical systems as found in High Reliability Organizations. And finally, I will present a summary of the empirical results of an alternate methodology for measuring perceived changes in safety at the operational level as leading indicators of evolving safety at at the organizational level

Jousting with dragons: A resilience engineering approach to managing SMS in the transport sector

System resilience is the ability for complex, dynamic-adaptive socio-technical systems to absorb and rebound from trauma or stress, and to avoid "jousting with dragons" where results are uncertain and often fatal. In a safety context, the term "dragons" originates from Professor David Woods at Ohio State University and the relatively new field of Resilience Engineering. Dragons are an illustration for the consequence of "surprise" as depicted in ancient seafarer maps that filled the seas beyond the known boundaries of the ancient world with fire-breathing dragons, and certain death. In a modern day sense, dragons represent the unintended, and often unforeseen and unpredictable, consequences of crossing operational boundaries that are difficult to identify precisely, are often influenced by various actors, and are continually changing. In particular, due to the complex, dynamic-adaptive behaviour of systems, classic statistical metrics used in current Safety Management Systems (SMS) no longer allow us to predict the next undesired event. We need to change our focus and find new ways of capturing the faint signals of impending failure. This will require structural, psychological and social changes in the way SMSs work. In this paper, I will address the issues of understanding and managing complex, dynamic-adaptive systems through the quality of resilience, and how to avoid "jousting with dragons" in the transport sector using a Resilience Engineering lens

Measuring the effects of strategic change on safety in a high reliability organization

This study explores how strategic organizational change affects safety as an outcome variable in a high reliability organization (HRO). High reliability organizations are defined as organizations operating in high-risk industries that achieve exceptionally high levels of safety performance. Based on the assumption that HROs achieve these high levels of safety performance through stable safety processes produced by common organizational structures such as: learning environments, highly regulated activities, redundancy, local ownership of tasks, and strong supporting safety cultures, I will study how potentially destabilizing deliberate change processes affect safety as an outcome, over time, in a live single longitudinal case study. This study sets out to answer two questions: (1) How does the interaction between leadership choices and actions, and organizational culture type affect attitudes towards change in a high reliability organization? (2) How do the relationships between leadership choices and actions during strategic change, safety climate in place, and employee attitudes toward change, affect safety as an outcome variable? A deliberate strategic change initiative known as corporatization is studied over a three year period in the Norwegian air navigation services provider - Avinor - with particular focus upon four embedded units that experience three different phases of a common deliberate change process. The findings indicate that the individuals at each embedded unit experience the change process differently regarding both the local leadership and the safety climate in place with varying effects on attitudes and perceptions. However, the findings also show that the attitudes and perceptions toward the top leadership, and the top leadership’s commitment to safety, in particular, are consistently reduced during the time period studied and do not vary across the embedded units. This study focuses on how a mismatch between organizational culture type and strategic change type affects change implementation success. Furthermore, the study shows how this mismatch affects individual attitudes and perceptions toward change, and how these, in turn, affect perceptions of safety for front-line employees directly responsible for safety outcomes. It is argued that different organizational culture types demand specific change types to ensure success. It is also argued that a mismatch between culture and change types can lead to a loss of trust in the leadership and resistance to change that can, in the worst case, lead to the collapse of the change process. Propositions on how changes in perceptions and attitudes affect safety are presented in a structural equation model, and show that individual perceptions of the leadership’s commitment to safety and safety climate have strong positive causal relationships to both attitudes toward change and perceptions of safety. The findings indicate that individual perceptions of the leadership’s commitment to safety have important implications to both change success and safety as an outcome