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FEDERAL AVIATION ADMINISTRATION

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FOURTH ANNUAL INTERNATIONAL AVIATION

SAFETY FORUM

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Thursday, November 29, 2007

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BREAKOUT PANEL D

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The panel met in Grand Dominion room II, IV

\+ VI in the Westfield Marriott Hotel, 14750

Conference Center Drive, Chantilly, Virginia, at

3:19 p.m., Nancy J. Graham, moderator, presiding.

PANEL MEMBERS:

NANCY J. GRAHAM Director, Air Navigation

Bureau, International Civil

Aviation Organization

STEVEN J. GROSSMAN Director of Aviation, Port

of Oakland

DR. STEVEN PREDMORE Vice President and Chief

Safety Officer, JetBlue

ATO GIRMA WAKE Chief Executive Officer,

Ethiopian Airlines

RAMESH LUTCHMEDIAL Director General of Civil

Aviation, Trinidad and

Tobago Civil Aviation

Authority

KIM CHOON LIM Director General and Chief

Executive Officer, Civil

Aviation Authority,

Singapore

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TABLE OF CONTENTS

ITEM: PAGE

Opening/Introduction of Moderator 3

Steve Wallace

Director, Accident Investigation

Federal Aviation Administration

Moderator Opening Comments/

Introduction of Panel Members 4

Nancy J. Graham

Director, Air Navigation Bureau

International Civil Aviation

Organization (ICAO)

Panel Discussion 5

Audience Q and A to Panel Members 46

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1 P-R-O-C-E-E-D-I-N-G-S

2 (3:19 p.m.)

3 MR. WALLACE: We\'ve got a great topic

4 and a great panel here this afternoon. I\'m Steve

5 Wallace. I\'m the Director of the FAA Office of

6 Accident Investigation. I\'m just going to get

7 this panel started and really looking forward to

8 it. There\'s the topic \-- Supporting the Culture:

9 Safety Culture Enhancement.

10 I think that what\'s clearly emerged in

11 the sessions today, it\'s apparent to me from this

12 morning and this afternoon\'s session, that

13 there\'s a very strong worldwide consensus on the

14 value of SMS. I think this is a little more

15 focused perhaps on some of the challenges involve

16 in this critical pillar of SMS, that is setting

17 the safety culture where people are free to

18 report and make the best use of information.

19 We\'ve got a fabulous international panel here and

20 we\'re going to try to allow maybe a little more

21 time than has been the average for questions from

22 the audience. We\'re also very luck to have an

23 excellent moderator in Nancy Graham who brings a

24 wealth of international experience to this panel.

25 Nancy is currently the Director of the Air

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1 Navigation Bureau at ICAO, and previous to that

2 was the Director of the FAA Area Office in

3 Singapore handling Asia and the Far East and

4 before that, held many positions involving

5 international work in the air traffic

6 organizations. So with that, I\'ll turn it over

7 to Nancy.

8 MS. GRAHAM: Thank you very much. I

9 appreciate that. And we are your last panel of

10 the day, so that\'s the good and the bad news.

11 The best news, I think, is that our intent is to

12 be very informal and for me, this is one of my

13 very favorite subjects. It\'s the subject that

14 really is about people. So technically, it\'s

15 actually called something else. It\'s called

16 Safety Culture Enhancement and Promotion, but I\'m

17 going to say it\'s about people.

18 So let me introduce this very

19 distinguished panel, and if you will indulge me,

20 I will not go into detail about their resumes.

21 They\'re all available in the handout, and we\'ll

22 just drive right into the substance of the

23 discussion. So to my far left, let me please

24 introduce Girma Wake. He is the Chief Executive

25 Officer for Ethiopian Airlines. We\'re delighted

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1 to have him, came from a long way to be here, so

2 definitely delighted to have him.

3 And to my immediate left is Ramesh

4 Lutchmedial. He is the DG of the Civil Aviation

5 Authority in Trinidad and Tobago. Woo-hoo,

6 wouldn\'t you all like to be here today.

7 To my immediate right is Dr. Steve

8 Predmore. He\'s the Vice President and Chief

9 Safety Officer for JetBlue, an airline we\'ve

10 heard a lot about. Welcome.

11 And to his right is Kim Choon Lin. He

12 is the Director General for the Civil Aviation

13 Authority of Singapore as well as the CEO for

14 Changi Airport, came all the way from Singapore.

15 Thank you very much.

16 And to the far right is Steve

17 Grossman. He\'s the Director of Aviation for

18 Oakland International Airport and delighted to

19 have you.

20 So it\'s a great panel. If you will

21 allow me, I\'ll just dive right in and start

22 firing off some questions and we plan to go until

23 we run out of gas here, and then we\'re going to

24 take some questions from the audience. So let me

25 start first with a bit about people in general.

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1 We all know that at the end of the day, people

2 are really the only asset that you have, and

3 safety culture is really about people and how

4 people adopt a willingness to look further back

5 into the system to really evaluate early on the

6 challenges that can sometimes turn into

7 incidents.

8 So with that in mind, I will ask for

9 the panel to begin with a discussion about what

10 you view as the biggest challenges to enhancing a

11 safety culture. Who\'d like to start? You can

12 tell Steve\'s jumping.

13 MR. GROSSMAN: Yes, I probably am. I

14 do think that working with people now is the

15 biggest challenge that we face and particularly,

16 you know, we\'ve talked about this morning \--

17 talked about this being the golden age of safety.

18 And perhaps that\'s true if you\'re measuring

19 safety in hull losses which seems like a strange

20 to measure to me. But in the bigger scale, I

21 think particularly at airports, we\'re just in the

22 first phases of our concern about safety, and it

23 is all about culture.

24 Many years ago, about 12 years ago at

25 Oakland, we established three priorities for our

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1 folks to worry about, and that was safety,

2 security and customer service, and it takes years

3 to get that through that people will understand

4 that if they\'re operating within those three

5 things, then they\'re pretty safe if that\'s how

6 they made decisions. But in order to achieve

7 that culture, it takes dedication, really, from

8 the top and it\'s not so much the folks in this

9 room or in the next room, because we\'re kind of

10 preaching to the choir here, but it\'s really at

11 that CEO level that you have to have a passion

12 for the subject. Because that passion gets

13 transmitted down to the rest of the staff and

14 it\'s \-- it can\'t become the flavor of the day.

15 In business schools all across the

16 world, they teach that as far as you have to have

17 consistency, you\'ve got to have that passion,

18 because if it leaves, if you got it and then a

19 year or two later that CEO leaves, a new CEO

20 comes in, you\'ve got a new flavor of the day, and

21 it won\'t get down to the lower ranks, because it

22 really doesn\'t matter how safe I am. It matters

23 how safe the custodians are. It matters how safe

24 the people working on the ramp are.

25 And again, I\'m coming from an airport

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1 perspective which is a bit narrower than what

2 many folks here are looking, but those are the

3 reports that I see. I see the reports every day

4 of accidents on the ramp and there are many

5 causes which we\'ll get into later, but it comes

6 down to a long-term consistency of promoting

7 safety, putting processes in place, etcetera.

8 MS. GRAHAM: Thank you for that.

9 Other thoughts?

10 MR. LUTCHMEDIAL: Yes. Safety culture

11 is about every person in the organization from

12 the CEO or the Chief Executive Officer, to the

13 person who cleans the floors. Many definitions

14 of safety culture are being preferred, but I like

15 best the one by the British Airlines Safety

16 Commission which defines safety culture as the

17 productive individual and group values,

18 attitudes, competencies and patterns of behavior

19 that determines the commitment to understanding

20 the professionals in our organization held on

21 safety programs.

22 In other words, what you\'re saying

23 here is that a safety culture of an organization

24 is what the organization creates by its attitude

25 towards safety. Attitude can be defined as a

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1 hypothetical construct that represents a person\'s

2 like or dislike for particular attitude.

3 Attitude comes from our judgment and can either

4 be positive or negative relative to the

5 organization\'s safety culture. Attitude drives

6 behavior, and it can change as a result of

7 training experience.

8 Attitude starts from the very top. For

9 example, a CEO who redirects funds for a well-

10 needed safety training program and opts to spend

11 it on a new capital project as part of an

12 expansion, trust, you very well run the risk of

13 accidents that may lead to significant losses in

14 revenue or perhaps the closure of his business.

15 The most important attitude to a

16 positive safety culture is the blame attitude.

17 First blame always goes to the lower person who

18 caught the mistake in the first place. But when

19 you do any kind of root cause analysis, you

20 normally find it was a result of something that

21 management at the top overlooked. They do not

22 place enough focus on training programs or

23 ensuring that they invest in up to date and

24 modern environment equipment, human resources and

25 training.

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1 So in order to force a healthy or

2 embracing positive safety culture, attitude

3 change and the extension behavior, it must not be

4 forced. It must be influenced by a proactive

5 organizational environment that is just,

6 flexible, learning and informed. People must not

7 be forced or commanded to do or not to do things.

8 Furthermore, the organization must be educated on

9 the consequences of not having a positive

10 attitude toward safety culture.

11 MS. GRAHAM: Thank you. Great. Okay.

12 DR. PREDEMORE: Well, I was just

13 going to say I think it\'s hard to top that. I

14 think you\'ve got all the major elements, or what

15 I would think, you know, beginning with senior

16 level commitment and commitment not just in words

17 but actions through investment in training,

18 investment in equipment and tools so that people

19 have the right tools and the things that they

20 need to do their job safely.

21 But, you know, I think it\'s also \--

22 you know, we talk about safety and a culture of

23 safe \-- first of all, you\'ve got a safety

24 culture. You know, it may not be the one you

25 want, but you\'re going to have a culture of

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1 safety that looks like something. And when we

2 talk about safety, it\'s always a look back.

3 Safety is always an evaluation that has or hasn\'t

4 happened in the past. And when you look at the

5 types of mistakes people made and make and the

6 errors that lead to the adverse consequences,

7 rarely is it the case that it was a clear

8 decision between safe or unsafe act. All sorts

9 of things come into play.

10 So it\'s about, you know, how do you

11 sort of structure the workplace and provide the

12 tools and resources that people need to make good

13 decisions evaluating the risks associated with

14 that and maintain that over time.

15 MS. GRAHAM: Yes, great. It would be

16 hard to disagree with any of the things that you

17 said. Girma, you\'ve got some thoughts on that?

18 MR. WAKE: I agree attitude is very

19 important and the attitude of the CEO, everybody

20 in the organization is important to world safety

21 culture. But I believe, as Giovanni mentioned in

22 the morning, Africa is reputed to be a problem

23 area as far as safety is concerned. I think to

24 understand \-- to find the solution for safety

25 problems in Africa, you would have to understand

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1 the problems, too. Basically, it is a question

2 of training, but I met many training schools,

3 training institutions in Africa that really train

4 pilots, technicians, ground support people to the

5 level of efficiency, the level of \-- to the level

6 that is required, one is that.

7 The other is even those who are

8 trained, because of the standard of salary that

9 is being paid in Africa, many of them are

10 recruited by other developed countries, by other

11 countries that can pay more. And therefore,

12 Africa\'s brain-drained as far as pilots, as far

13 as technicians, as far as other support staff are

14 concerned. It is very, very high. And Africa

15 would have to find a solution to the brain-drain

16 that it is suffering from today.

17 The other is I believe Africa would

18 have to clean up its own act. There are a number

19 of carriers, old airplanes that are registered in

20 Africa which have nothing to do with Africa.

21 These are airplanes that are not allowed to fly

22 anywhere else. They come, register in Africa and

23 try to fly from Point A to B but remain in the

24 bush somewhere or cause an accident for somebody

25 else.

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1 So I believe our officials would have

2 to be committed to the fact that Africa would

3 have to be \-- African air space would have to be

4 safe and therefore should have to be disciplined

5 not to give that type of license to air cars that

6 are not air worthy. I believe if Africa solved

7 some of these problems, I think the safety

8 culture will be easier to develop than it is

9 today.

10 MS. GRAHAM: Thank you. That\'s very

11 candid on your part. I appreciate that very much

12 and it would remiss of me not to take the

13 opportunity to say that ICAO, of course, agrees

14 with you in terms of the flags of convenience.

15 And my predecessor, Bill Voss, who I know is

16 floating around here somewhere today, has started

17 before me a very aggressive process, and just in

18 the last few months, ICAO has taken actions

19 against two states that have been very much

20 focused on flights of convenience. So thank you

21 for mentioning that.

22 And what about in Singapore? How do

23 you deal with some of the challenges?

24 MR. LIN: I think to develop a safety

25 culture that can last, other than the points that

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1 have been raised by the panel members, I\'d just

2 to put forth three points. One I think foremost

3 is that first the attitude of the CEO or the

4 decision maker within that particular

5 organization must believe that they can develop a

6 safety culture. If they don\'t believe that they

7 can, then obviously, they won\'t be able to. So I

8 think that\'s the first step.

9 And in then the next step would be to

10 go about setting up a holistic system whereby you

11 look at all measures from even punitive measures

12 all the way to collaborative measures, looking at

13 various layers of the organization and various of

14 the organization, looking at assessment as to

15 what level these organizations are and applying

16 the right methodology to foster the safety

17 culture.

18 And the last issue really is about

19 people, I mean, really, to put the right people

20 into your safety organization. In Singapore, and

21 to some degree in developing countries, you tend

22 to find that people who take up safety positions

23 are either taking it on as a second job. Or the

24 people who are not really the rising stars of the

25 organizations are basically given the safety job.

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1 So in a sense, you can see then that the way the

2 safety in the particular is quite, almost

3 directly, proportionate to the type of people you

4 put into the particular jobs itself.

5 MS. GRAHAM: Okay. Thank you. So we

6 heard about some special challenges in Africa,

7 but in general, I think what the panel \-- and

8 it\'s been reinforced throughout the day \-- is

9 creating a proactive environment, being very

10 passionate about the topic, really believing in

11 safety management as a system, focusing on a

12 holistic structure and providing tools for

13 actually do the work and the proper kind of

14 training in the proper kind of environment.

15 So moving on then with as you begin to

16 set up a safety system and as you said earlier,

17 you have one whether it\'s what you want or not,

18 to move it to a more proactive scheme, how do you

19 address and how have you possibly addressed just

20 the normal resistance that comes along with

21 change. People just typically are not

22 enthusiastic about change. Or in fact, you have

23 the wide varieties. You have some people that

24 are change agents that love it and thrive on it,

25 and people that really, really drag their feet,

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1 and then the 90 percent in the middle. So have

2 you dealt with that in your organizations?

3 DR. PREDMORE: I think you have to

4 make it real to people. I mean first of all,

5 what\'s the benefit? Whether you\'re trying to

6 convince senior leadership or the front line crew

7 member, what\'s in it for them? And so, you know,

8 senior management, one way that we have found, I

9 think as an industry, that to make this real is

10 you capture it more in terms of quality

11 improvement. You know, we view safety as an

12 element of quality, overall quality.

13 And typically, our experience has been

14 that stations or departments or areas where we\'ve

15 seen a less than desirable safety record, we\'ve

16 seen a less than desirable operational record as

17 well. Because, you know, at the end of the day,

18 you\'re really talking about human performance and

19 decision making and the same basic elements. So

20 to the extent that you can drive improvements

21 that enhance your level of safety, you\'re

22 probably improving quality as well and vice-

23 versa.

24 For the front line crew member, again,

25 it\'s making it real. It\'s, you know, if you\'re

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1 trying to create are porting structure which is a

2 key element of SMS, what\'s in it for the crew

3 member to report whatever the hazard is or the

4 risk. Do you feed that information back? Do you

5 make use of it? So you have to find a way to

6 make it real and, ideally, measurable to all

7 levels of the organization.

8 MS. GRAHAM: And how do you do that in

9 JetBlue?

10 DR. PREDMORE: For example, we\'ve got

11 a number of feedback systems that we use, again,

12 with front line crew members, with briefings with

13 senior managers, and I think most airlines do

14 this. They do it in different ways. And I think

15 that\'s really key \-- that there\'s not a way to do

16 any of this. You\'ve got to develop, you know,

17 the communication process and the reporting

18 processes and the rules and framework around

19 that, but it\'s your particular culture. You

20 know, we have a number of ways that we feed that

21 information back \-- just as an example.

22 MS. GRAHAM: And you tell it\'s real by

23 the results?

24 DR. PREDMORE: Yes, absolutely.

25 That\'s right. I mean measurement is so critical

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1 here. You know, at the end of the day, are

2 things getting better or not getting better and,

3 if so, why, so.

4 MS. GRAHAM: Super. Okay. Thank you

5 for that. Other areas where you\'ve created

6 change and overcome the resistance?

7 MR. LUTCHMEDIAL: Well, a lot of

8 people seem to think that having a safety program

9 is having a safety culture. There are clearly

10 two distinct things, and therefore people who

11 have very good programs, you still have accident

12 risks because the difference is they don\'t have a

13 safety culture. And then when you tell them they

14 don\'t have a safety culture, they try to build

15 one overnight. You cannot build a safety culture

16 overnight. It takes time. It takes between

17 three to five years minimum, and it has to be

18 driven from the top down. You cannot \-- safety

19 cultures aren\'t about one or two people or small

20 departments within an organization. It is a

21 collective effort on the part of the entire

22 organization and it has to be driven top down,

23 from the top \-- from the board of directors, from

24 the CEO all the way down. You can\'t have people

25 \-- in some organizations, I know about we charge

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1 a department for developing and promoting safety

2 culture but they have no resources. They have no

3 money. They have no staff. There\'s nothing to

4 do and then you blame them. It must be driven by

5 the top down, and I really believe we can measure

6 the effectiveness of our safety culture by

7 whether we are a reduction in incidents or

8 accidents so it continues to increase.

9 MS. GRAHAM: Okay.

10 MR. GROSSMAN: You know, Nancy, to

11 build on that, I\'ve seen a number of workgroups,

12 mostly probably in the blue collar area, where

13 they take a lot of pride in accomplishing their

14 jobs under very adverse conditions, and those

15 adverse conditions might include some very unsafe

16 conditions. And what we\'ve tried to do is make

17 sure that those folks know that management will

18 support them in getting resources to make their

19 jobs better. And it takes time. It does.

20 It takes time to get it across that,

21 you know, if there\'s a tool that they need, if

22 there\'s a piece of equipment that they need that

23 can make the job safer and better, we\'re going to

24 get that to them. All they have to do is

25 identify it. It\'s not something that I can

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1 identify for them, which is sometimes what they

2 wait for. But if internally they can identify

3 here\'s what we need \-- well, maybe in years gone

4 by somebody said, well, it\'s not in the budget,

5 you can\'t have it. In our case, you know, I view

6 budgets as guidelines and if somebody comes up

7 with a good idea, we\'re going to get that piece

8 of equipment.

9 And it takes a little bit of time to

10 get that across, but all of a sudden, now they

11 can take pride not only getting the job done, but

12 in getting it done in a much safer manner.

13 MS. GRAHAM: So you demonstrate both

14 your commitment from the senior level in terms of

15 the resources that are allocated and also just

16 response to a request for that?

17 MR. GROSSMAN: Money talks.

18 MS. GRAHAM: Money talks, indeed.

19 Please?

20 MR. LIN: Sometimes what you need to

21 do is just set some performance standards,

22 safety, KPS if you like, and make it visible for

23 everybody. And sometimes you\'d be surprised at

24 how little things that the CEO does would

25 actually translate down to the people on the

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1 ground itself.

2 For example, in Changi Airport, I make

3 it a point to have safety as number one on the

4 agenda a weekly basis, and we look at all

5 incidents and accidents. And basically, we spend

6 a fair amount of our time discussing those

7 incidents, what were the lessons learned and ask

8 other organizations within Changi, how do you

9 then apply the lessons that have been learned

10 from a particular incident to your organization?

11 The situation may not be the same, but the

12 lessons that that particular organization learned

13 can be applicable to you in perhaps different

14 circumstances altogether.

15 So you get your way by walking the

16 talk, if you like, as you say. But it is a long

17 process and you have to continuously repeat

18 yourself again and again and again, and then you

19 just make sure that \-- but once that is done from

20 the very top, you\'ll find it starts to percolate

21 downwards into the organization. And over time,

22 hopefully, you will then ingrain it into the

23 other people such that ultimately, over a long

24 time, you become a safety culture.

25 MS. GRAHAM: Makes great sense. So it

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1 must be doubly hard then for you as well as you

2 have quite a lot of turnover generally speaking,

3 as you were mentioning before, to keep people

4 very enthusiastic then as they see that turnover.

5 How do you deal with that challenge?

6 MR. WAKE: I believe first of all, it

7 has to start from the recruitment. When you

8 recruit people, you have to look for people with

9 the right attitude. It\'s easier to train a

10 person who has the right attitude than to get

11 somebody with the wrong attitude and try to

12 change it. So I think it has to \-- recruitment

13 itself should be built on that attitude. You

14 know, should be able to evaluate the attitude of

15 the person, whether he\'s the type who is flexible

16 to learning new ideas or whether he\'s the type

17 who would stick to some idea and who doesn\'t want

18 to change. So recruitment will have \-- during

19 recruitment, most of these things will have to be

20 cleared.

21 The other is once you have the person,

22 I think you have to convince them that a safe way

23 of working is better for him, better for his

24 organization, and the result will be better for

25 everybody else. Train and also convince that it

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1 is right. There are people, no matter how much

2 you preach, no matter how much you try, no matter

3 how much you set an example, there are people who

4 have difficulty to change. You should have the

5 guts to say I have no place for you, because you

6 cannot compromise safety because you don\'t want

7 to do anything to one or two or three or ten

8 people. I think people will have to get the

9 message that safety is not something that has to

10 be compromised for the sake of anybody. That

11 will have to be very clear.

12 And as one said, you have to walk \--

13 you have to do what you preach. You cannot tell

14 people one thing and do something else. More

15 than that, I think the general attitude \-- you

16 know, when you work at an airport, it\'s not just

17 the airline or the airport authority or the civil

18 aviation, there are a lot of other parties on the

19 airport. These parties would have to be brought

20 in and there must be a discussion between anybody

21 who is concerned with the activities at the

22 airport, be it a fueling company, be it the

23 police, and convince them that working together

24 and trying to make the situation safer is to the

25 advantage of everybody else. That will have to

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1 work.

2 And among airline, I think the best

3 thing to do is to collect different departments,

4 representatives of different departments to sit

5 together and discuss issues concerning safety.

6 If the pilot would sit there and tell a

7 technician the way you fix an airplane, the way

8 you dispatch me is wrong and it\'s unsafe, the

9 technician will start thinking twice. And if the

10 technician tells the pilot that the way you fly

11 the airplane, the way you handle it is wrong, and

12 not in a very negative way, but in a way of

13 telling one another, let\'s both correct and see

14 that it works for us. Because no matter how much

15 you talk to both of them, from the fear, people

16 may do it. But I think when they sit with their

17 peers and discuss between themselves and they see

18 how they can support one another, I think they

19 will achieve a better result. And that is the

20 culture that has to be built within an

21 organization.

22 And if, for example, a technician is

23 short of parts and simply recalls he wants to

24 dispatch a flight on time and there are things

25 that should not be done, one should be able to

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1 put down and say, look, if that flight has to be

2 cancelled, it has to be cancelled because we

3 don\'t want anything unsafe.

4 MS. GRAHAM: So they have to know they

5 have the authority to do \--

6 MR. WAKE: They have to know that and

7 they have to know that they have that right. In

8 many organizations, people believe if they don\'t

9 send the flight on time, they are going to

10 suffer, that it\'s going to be a problem for them,

11 and therefore, they will do anything to send it

12 off. That attitude will have to change and

13 management would have to make it clear to

14 everybody that it\'s not only dispatching the

15 flight, which is important, it is dispatching the

16 flight safely, which is more important. And that

17 message would have to get through to \--

18 MS. GRAHAM: Great. Okay. Thank you.

19 I'm dating myself a little here, but when I was a

20 torpedo mechanic, I remember the first time I \--

21 I\'m not kidding \-- I remember the first time that

22 I joined a Quality Circle. Does anybody else

23 remember Quality Circles?

24 MR. WAKE: Yes.

25 MS. GRAHAM: And I thought that was

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1 just the neatest thing, because it gave me the

2 broader understanding of another component that I

3 hadn\'t worked on previously or \-- and we did

4 statistics and I thought that was just very cool.

5 And it gave me a broader understanding of a lot

6 of issues. And, I think for me, I have continued

7 to see that throughout my career that anytime you

8 show someone a broader picture, it gives them the

9 ability to think in a different way, and I think

10 partly that\'s, to some extent, what SMS does is

11 it gives you the broader picture and it allows

12 you to look back in time before you \-- as far

13 back in time as you can to make an assessment

14 earlier on, so.

15 MR. LIN: I\'d just like to \-- sorry

16 for interrupting you.

17 MS. GRAHAM: Please, no.

18 MR. LIN: But just to put a

19 perspective on if you want to build a safety

20 system and you want to build a safety culture, if

21 you initially have a lousy one, it\'s actually

22 very easy to start to build a good one, because

23 you can see the results as you build your safety

24 system as a safety culture starts to apply. It

25 is only when you have a fairly good safety

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1 culture in place that \-- and you keep doing well

2 and you don\'t see any results \-- I think the

3 funny thing about safety is the more you do, the

4 less results you get, which is actually correct.

5 You shouldn\'t get \-- the more you do, you should

6 have more, not less result \-- the complacency

7 begins to set in. And then what you have done or

8 what time, if you don\'t continuously monitor it,

9 you will find that unsafe habits will start to

10 creep in, and then you will be hit in the world

11 by something fairly nasty.

12 Before I turned CS, I was in the air

13 force, and we had a chief who, in 1989, said that

14 we will go for zero accidents. Obviously, all of

15 us were in disbelief. You know, you\'re flying

16 fighters. You\'re flying helicopters. You\'re

17 flying transport, doing all kinds of things. How

18 can you ever have zero accidents. But he

19 persisted and he persisted and then the next

20 chief that took over, the assistant, and after

21 about five years of persistence, we had our very

22 first year of zero accidents.

23 And then it continued for another

24 seven years of zero accidents. And we thought we

25 had it good. And that was when I took over as

Page 28

1 Chief. And then we started having crashes again.

2 MS. GRAHAM: Just after you took over

3 as Chief.

4 MR. LIN: Just after I took over \--

5 MS. GRAHAM: Oh, oh.

6 MR. LIN: \-- so it\'s probably me. So

7 we started to have the first crash, and quickly,

8 within six months, we had a second crash. So

9 what we did was, sure, we\'ll do a review of the

10 whole entire safety system, the entire

11 operational system, and we found what has

12 happened over time was that bad habits had

13 started to creep into our safety management

14 system. And we quickly removed those bad habits

15 and reemphasized, and we went back to basics

16 again, and then we redid the process from start

17 again, but this time from a higher level rather

18 than a lower level instead.

19 So while building a safety system

20 seems difficult enough, it is actually the easy

21 part, because you start to pluck the low hanging

22 fruits. It\'s when you get into the golden age of

23 air travel and when you think that whatever you

24 have put in place is working and should sustain

25 you, I think that is where your antennas should

Page 29

1 be up and we should be a lot more alert. And the

2 level of scrutiny that you put in place should

3 increase a bit more, because if you don\'t, then

4 you\'ll find that all these bad habits will start

5 to creep in, and then you will have a catastrophe

6 somewhere down the road.

7 MS. GRAHAM: So one could argue that

8 that\'s exactly where the industry is at this

9 point is in the golden age of safety, and we are

10 at the point where we\'ve had, for a number of

11 years, an extraordinarily low record. So given

12 that, it sort of leads me into the next question

13 which is how do you keep safety management from

14 being a bumper sticker? So Quality Circles after

15 a while became a bumper sticker, and then it was

16 quality management and, you know, on and on from

17 there. Given what you just said, then how do you

18 keep it fresh and how do you know when you need

19 to refresh? Any thoughts on that?

20 DR. PREDMORE: Well, I think \-- you

21 know, you said something I think is so

22 important, and Mick talked about it this morning

23 in his comments that, you know, SMS is not a

24 panacea. It\'s not a solution to all things. And

25 this is why this discussion of culture, I think,

Page 30

1 is so important to where we want to go, because

2 SMS was going to provide a framework, some

3 process. But if the underlying culture does not

4 support safe performance, then SMS isn\'t going to

5 be successful, because what SMS will do is allow

6 us to institutionalize those processes, and in

7 some very structured ways. But if you\'re

8 institutionalizing a poor culture, you\'re not

9 going to end up, I think, any farther along then

10 where you started.

11 We just did a renovation in my house,

12 so my entire world view is based on going through

13 a house renovation. I sort of think of SMS as

14 kind of the building codes and, you know, the

15 requirements and the structure for creating a

16 safe home, a safe structure. But, you know, it\'s

17 the culture that makes the home look like a home

18 and decides. You can have the codes but the

19 codes don\'t determine what the house looks like

20 at the end of the day. That\'s based on the needs

21 and values and desires and experiences of the

22 family that lives there.

23 And I think that\'s kind of a good

24 analogy for how a company works and develops a

25 safety culture. It\'s the shared expectations and

Page 31

1 values and experiences and tools that the company

2 has that when you lay SMS on top of that, you

3 know, you have the potential to be successful

4 over the long term, because at the end of the

5 day, it will help you to institutionalize those

6 processes and maintain them over a period of time

7 so that you don\'t get complacent.

8 MS. GRAHAM: Other thoughts?

9 MR. LUTCHMEDIAL: Well, I really would

10 like commitment, because commitment is a key

11 element of the whole safety culture, and I feel

12 very happy when I go to an organization and in

13 every department you see a statement of safety

14 policy affirmed by the board of directors. And

15 what it tells employees is that you have the

16 support of the board. And therefore, the things

17 that the policy says, right, you can rest

18 comfortably that you can go and actually do the

19 right thing even if it means, as my friend here,

20 cancel the flight, and know that nobody\'s going

21 to take action against you for not meeting what

22 we call the commercial objectives. Because a lot

23 of people \-- mechanics, pilots, they come to work

24 and we show pressures to get the flight or to get

25 it on time, and sometimes pressures move people

Page 32

1 to overlook very little things that can create a

2 chain reaction that can cause an accident.

3 But when you have a well-defined and

4 well-articulated safety policy affirmed by the

5 board or the CEO, then people should be

6 comfortable doing the right thing and know that

7 there will be no recrimination thereafter. I

8 think that\'s important it be done in building

9 that safety culture.

10 MS. GRAHAM: You raise an interesting

11 point which is how do you know or what kinds of

12 things in an environment make you know that you

13 have the support of management other than walking

14 the talk. But that\'s interesting that something

15 on the wall would make you feel reassured to an

16 extent. That\'s great. Okay. Anybody else?

17 MR. LIN: I just wanted to add that \--

18 I mean this is not based on any scientific theory

19 whatsoever, but just going back to the experience

20 of the air force. In my days in the air force,

21 when we started the zero accident philosophy and

22 we started getting people to openly report

23 incidents largely, we noticed a very positive

24 correlation between the number of reports that

25 you get vis-à-vis the number of accidents, also

Page 33

1 inverse correlation. The more reports you gave

2 respect to, other incidents, near misses or

3 whatever, the more you get of those, the less

4 incidents we got.

5 And what happened is, in essence, we

6 lost track a little bit and we didn\'t monitor too

7 closely because we were so comfortable with the

8 state of the safety system that we had. When we

9 had that first accident after seven years, we

10 then went and took a look at the monthly and

11 weekly incident reporting, and we noticed that it

12 was beginning to trend downwards, the number of

13 incidents that have been reported, upwards. It

14 was beginning to trend downwards. And to a point

15 whereby until we had the first accident, and then

16 when the trend started going back upwards again,

17 that was when we were able to reduce the number

18 of incidents.

19 So it\'s a kind of, if you like,

20 indicator as to whether you\'re people are on the

21 lookout for unsafe acts. I mean if they keep \--

22 if the reports keep coming out that there were

23 unsafe acts being carried, there was incidents

24 being reported, then at least you\'re assured that

25 people are still a bit more safety-minded and

Page 34

1 still on the lookout for things. And if the

2 reports start to reduce, then you should be a

3 little bit more alert \--

4 MS. GRAHAM: That\'s interesting

5 because it\'s not necessarily the intuitive. It\'s

6 the opposite.

7 MR. LIN: It is directly the opposite,

8 yes.

9 MS. GRAHAM: Interesting. Anybody

10 else agree with that?

11 DR. PREDMORE: Absolutely.

12 MS. GRAHAM: Absolutely? Okay.

13 MR. GROSSMAN: I mean keeping in mind

14 that safety, you\'re dealing with people, in some

15 respects where you can in instances, we have to

16 make safety fun as well. I mean a year or two

17 ago, we established a FOD czar at the airport.

18 MS. GRAHAM: Now say what that is?

19 Tell us about the \--

20 MR. GROSSMAN: Fun Object Debris and

21 what we did was \--

22 MS. GRAHAM: I thought it was like a

23 FONSI thing. I thought you said Fonsi \--

24 MR. GROSSMAN: It kind of is.

25 MS. GRAHAM: Okay.

Page 35

1 MR. GROSSMAN: It is kind of like that

2 and he things of himself as Fonsi.

3 MS. GRAHAM: Okay.

4 MR. GROSSMAN: But what we Domestic

5 Industry is he collects groups of our tenants,

6 and he takes these FOD walks monthly. And they

7 have a good time doing it. And at the end of the

8 FOD walk, you know, they all have lunch together

9 and they talk about, you know, what they found

10 and whatever, but it\'s a good time. And I think

11 the more you can do that, the more people buy

12 into that collective experience of this makes a

13 lot o sense. So not only is safety good for

14 business, but they have fun doing it. And people

15 just react better when parts of their jobs are

16 fun.

17 MS. GRAHAM: I totally agree.

18 MR. GROSSMAN: So, you know, in small

19 cases, I think you can do it.

20 MS. GRAHAM: Any other innovative

21 approaches like that?

22 MR. WAKE: I believe once you maintain

23 a good safety record, you have to work on the

24 monitoring of that system. And probably you have

25 to do it often. If you neglect it for three,

Page 36

1 four, five, six months, I think people will think

2 that you are not serious enough, probably hold a

3 meeting of the top people once a month, involve

4 other people, talk about it. Any incident that

5 was reported, bring it up, discuss it. Then

6 people will know that it is serious.

7 The other thing is keep on training

8 people and retraining, because once a technician

9 knows how to handle a certain type of airplane,

10 he thinks he doesn\'t have to refer his book, he

11 doesn\'t have to think, he can just go and do it.

12 And I think working according to the procedure,

13 working according to the book, the importance of

14 that should be explained at every level. And I

15 think that can be done based through training.

16 And then you have to also work on retaining your

17 good people. If you train and train and you lose

18 them, you\'re back to square one, so you have to

19 find ways and means of retaining those people.

20 But at the same time, you will also

21 have to enlarge your pool of qualified people.

22 You have to bring in new blood, train them,

23 prepare them so that if the others leave, they

24 are already there and they will be able to take

25 the place of those who leave, or those who

Page 37

1 retire, or those, for some reason, leave the

2 company. The pool will have to be stronger and

3 stronger. And with that type of thing, I think

4 you can maintain a good safety record.

5 MS. GRAHAM: In fact, you\'re

6 absolutely right. ICAO\'s data says that there a

7 100 to 1000 incidents for every 1 to 5 accidents,

8 and the time to get worried is when you\'re

9 reporting data begins to go low. So I completely

10 agree with you and it is a bit counterintuitive,

11 but I think it\'s \-- out data shows it\'s

12 absolutely right.

13 So let\'s move on to another topic then

14 \-- measurement, because I think I heard you say

15 earlier or I had someone else say earlier that

16 you can\'t change what you can\'t measure and I

17 agree. But in the context of safety, how do you

18 measure or even should we measure a safety

19 culture?

20 DR. PREDMORE: Yes, I mean there are

21 outcomes obviously. We track very closely

22 damages and incidents and near misses, injuries,

23 flight incidents of various types, provided the

24 standard kinds of outcome measures fairly

25 closely. But I really think that, you know, if I

Page 38

1 were to point to one element of safety culture,

2 it really is a reporting culture and to what

3 degree are your people have been open and coming

4 forward and reporting things that maybe they

5 don\'t want to talk about and you don\'t want to

6 hear, and that\'s one of another sort of key

7 statistics that we look at is trends in reporting

8 over time.

9 MS. GRAHAM: And should we measure

10 culture? Should we do attitude surveys? Should

11 we measure culture?

12 DR. PREDMORE: Yes. I think it\'s a

13 good indication. When we talk about sort of

14 institutionalization through SMS and the

15 establishment and of SMS standards and so forth,

16 I\'m more concerned about what the front line

17 pilot, technician, ground ops worker thinks

18 about the safety culture at JetBlue than I am a

19 POI or outside of the company, but how\'s it

20 impacting that front line person, and so I think

21 surveys are a good way to get at that, if you\'ve

22 got a culture that supports open communication.

23 And I think that\'s always the question is how do

24 you know that you\'re getting honest feedback?

25 MR. GROSSMAN: It\'s also one of the

Page 39

1 biggest challenges, I think, we face in the U.S.

2 where airports are required by the FAA to have

3 consequences for safety violations, yet within

4 SMS, you\'re supposed to have a very open

5 reporting environment, and the two are in

6 conflict. You know, there\'s a logic to having

7 consequences but is that overridden by the need

8 to have this data to create a higher level of

9 safety? And I think that\'s the challenge that we

10 face is how do we draw that balance so that we

11 are finding out this information, people aren\'t

12 afraid that if, you know, even on the airline

13 side, if they report damage to an aircraft,

14 that\'s what they should be doing and not trying

15 to hide it because they might get in trouble for

16 it and on the airport side as well. So that\'s a

17 real challenge over the next few years as we

18 implement SMS in the U.S. as to how we do that.

19 MS. GRAHAM: Okay. Any other \--

20 MR. LUTCHMEDIAL: I think that the end

21 result is the reduction of incidents and

22 accidents, so if you have zero \-- well, that\'s

23 probably ideal \-- but if you have a significant

24 reduction, it means that you\'re safety culture is

25 working for you. If you think you have a safety

Page 40

1 culture but you see incidents and accidents

2 increasing, then something is wrong. And

3 therefore, a safety culture cannot be inflexible

4 It must be flexible and if we need to go back and

5 do your investigations, do your surveys to see

6 where did you go wrong or where did you need to

7 make a change, you may for instance \-- and it

8 happens when \-- we had an incident once where we

9 were moving from, you know, the conventional U-

10 type aircraft or airbus aircraft, and we had a

11 wingtip accident. And before I knew it, then

12 they were trying to induct the aircraft in a

13 short space of time. And therefore, they cut

14 down on the pilot training program, and they

15 eliminated the module on crosswind landings. And

16 therefore, he hit a crosswind, was in excess of

17 50 knots, couldn\'t be with it. The end result

18 was an accident.

19 So we then had put a procedure in

20 place that until every pilot went through a

21 program and module on crosswind landings, winds

22 that crossed in excess of 50 knots, they cannot

23 land. You know? So we had to go back and look

24 what wrong.

25 The other point I wanted to make \--

Page 41

1 maybe if I \-- which is about safety committees.

2 A lot of safety committees don\'t work, right?

3 They don\'t work for a number of reasons, the main

4 one being that the person who chairs the

5 committee is not empowered to make decisions. So

6 we collect \-- we have all the accidents reported,

7 we do all the analysis and we do all the required

8 investigations and we come up with

9 recommendations.

10 And month after month, these

11 recommendations are there unimplemented like a

12 recurring decimal, because the person who chairs

13 the committee doesn\'t have the authority, the

14 financial authority to go out and implement those

15 recommendations, buy the equipment, invest in new

16 \-- in training and procedures and so on. So

17 therefore, my recommendation is that if you were

18 to have a safety committee and for it to be

19 effective, it must be chaired by a person who has

20 the financial authority to go and do what is

21 required to be done to implement safety

22 recommendations.

23 MS. GRAHAM: Very interesting. So

24 that takes us to another question that I had

25 which is are there certain organizational

Page 42

1 structures that are more conducive to adopting

2 SMS than others, or is it just the committees,

3 etcetera? Is it any \-- is there an

4 organizational structure that\'s more optimum than

5 another for SMS? We heard your part of the

6 committees \-- make certain the person has the

7 financial authority to actually make the change

8 that\'s recommended. Okay. Any other thoughts on

9 that?

10 DR. PREDMORE: Yes. No, I don\'t think

11 there\'s a specific organizational structure. And

12 again, it goes back to, I think, when we talk

13 about SMS and global standards for SMS, you have

14 to \-- it has to be tailored to the specific

15 culture and organization that it\'s going to be

16 effective. And, you know, I don\'t think we\'ll

17 see this, and I certainly hope we don\'t, you

18 know, some standard that say you need to

19 structure your SMS in this way or that way. And

20 I think back to CRM and human factors and the

21 emergence of that, and I thought the way that

22 operators and the FAA and industry folks

23 approached that was I hope the way we adopt the

24 implementation of SMS, and that is let\'s lay out

25 the guiding principles, and then let\'s leave it

Page 43

1 to the airline to figure out to apply it in its

2 most effective way within their specific

3 operations, so \--

4 MS. GRAHAM: So the what, not the how.

5 DR. PREDMORE: I\'m sorry?

6 MS. GRAHAM: The what, not the how.

7 DR. PREDMORE: Yes, don\'t dictate the

8 how. Right.

9 MS. GRAHAM: Anybody else \-- thoughts

10 on organizational structures.

11 MR. LIN: I agree. I don\'t think

12 there\'s a specific organizational structure that

13 is more suitable for SMS. Even if there is, I

14 don\'t think most organizations will adopt it

15 either, because the structure, the organization,

16 they\'re calling to different needs, largely

17 economic and profit driven, but also there are

18 other factors that come into play.

19 So what is important for an SMS is

20 that it must be able to be adaptable, and it must

21 fit into the organizational structure that works

22 for the organization and not try and restructure

23 it to fit the SMS.

24 MS. GRAHAM: Okay. Let\'s move to the

25 future a little bit. So how do you see SMS in

Page 44

1 the context of fractional ownership, the new

2 emerging trend?

3 DR. PREDMORE: Fractional ownership \--

4 No, I can\'t \-- I certainly can\'t lay out what

5 that would like. You know, I was really

6 encouraged recently \-- I don\'t know if we have

7 anybody from Eclipse here \-- but, you know, one

8 of the sort of new generation fractional

9 ownership sort of organizations that just

10 recently introduced, I think, a FOQA program, and

11 it is, far as I know, kind of the first foray

12 into that part of the industry with programs like

13 FOQA, which I think is a huge step forward. And

14 it\'ll be interesting to see how that plays out

15 and how they make that work, and I am confident

16 that they will.

17 But when you look at sort of, again,

18 kind of the elements of SMS, you know, open

19 reporting systems and measurements and management

20 practices to support a safe culture, again, what

21 works in an airline is not going to work in that

22 kind of an organizational structure. So it\'s

23 going to have to sort of create it on their own

24 grabbing best practices where they can and then

25 figuring out what works in that kind of an

Page 45

1 environment.

2 MS. GRAHAM: So tailoring it for that

3 particular \--

4 DR. PREDMORE: Absolutely.

5 MR. GROSSMAN: I think they mentioned

6 it in the session before us, you won\'t get the

7 same level of expertise as you go down kind of in

8 the pecking order of aircraft, and so fractional

9 owners or aircraft operators may not be as expert

10 as airlines require their own pilots to be.

11 Owners of very light jets may be somewhat even

12 below that, etcetera. And so at least with an

13 SMS tailored for that group, you can bring the

14 level of awareness of safety up and improve the

15 records that have been out there.

16 MS. GRAHAM: Okay. Any other thoughts

17 on fractional ownership? Want to launch into

18 that one?

19 MR. LUTCHMEDIAL: I was going to say

20 perhaps as long as the fractional ownership is

21 domestic, you know, within the \-- when it\'s, you

22 know, across the border, then it becomes more

23 challenging because you\'re dealing all with

24 different regulations and different cultures, you

25 know, national cultures and that\'s going to make

Page 46

1 it more challenging.

2 MS. GRAHAM: Okay. I think it\'s time

3 to take some questions from the audience? What

4 do you think? Let\'s take some questions. I see

5 one or two. I see three or four. Great.

6 MR. KRIEGLER: Hi, Jacob Kriegler from

7 JetBlue Airways. I guess my question is in

8 regards to as we see a lot more third-party, you

9 know, maintenance contracts, mergers, how exactly

10 do we take, you know, whether it\'s the main

11 airline that\'s sort of consuming another or the

12 third-party vendor that\'s doing maintenance for a

13 company, how do you translate and transfer a

14 particular SMS over to that third party to make

15 sure that they\'re falling in line with your

16 standards? I mean Captain Yantiss talked about

17 this a little earlier with United and how they

18 try and set up some standards that they try and

19 keep the third parties to adhere to. But how do

20 you make that work?

21 MS. GRAHAM: So the question really is

22 then how do you look at a third-party maintainer

23 for instance, and how do you carry over, how do

24 you know they carried over your SMS principles,

25 correct? Yes, okay. Thoughts?

Page 47

1 MR. LIN: Can I ask you a question

2 instead? Are you assuming that a third party

3 safety system will be worse off than the airline

4 safety system, because I would have thought a

5 third-party maintainer would have a greater

6 economic interest to ensure that a safety

7 management system is up to par to the airline and

8 they would be a financial or contractual penalty

9 if it\'s not in order for them to secure the job

10 from the particular airline itself. So I\'m not

11 sure whether you come across with the assumption

12 that a third-party maintainer would actually have

13 lower safety standards vis-à-vis the airline

14 maintainer itself.

15 MR. KRIEGLER: No, I wouldn\'t assume

16 that. I think it can go both ways actually, so

17 maybe it\'s whoever has the higher standard, how

18 do you meet that gap if it exists?

19 MR. LUTCHMEDIAL: Well, one of the

20 things that happens, as you probably know, is

21 that if, for instance, like let\'s take in the

22 case of Tobago. We\'re the national carrier

23 there. We have certified as \-- given them a AOC,

24 and they then decided to come drop their seat

25 checks to Delta Airlines in Atlanta. But before

Page 48

1 they do that, they\'ll look over everybody as they

2 would at Delta to make sure that Delta MRO meets

3 all the national requirements of Tobago before

4 that role is imminent. That way we can capture

5 any deficiencies and insist \-- for instance, in

6 this case, Delta had to introduce international

7 procedures which caused the airline some money,

8 but at the end of it, there\'s regulators who

9 insisted that we would not approve Delta Airlines

10 to do maintenance on a local carrier unless these

11 requirements are met. And that\'s one way we can,

12 you know, capture all of the deficiencies in SMS

13 training or human factors which is now applicable

14 to maintenance personnel to ensure that safety is

15 not compromised.

16 MS. GRAHAM: So you, as the regulator,

17 required additional information, additional audit

18 of the third party?

19 MR. LUTCHMEDIAL: Yes.

20 MS. GRAHAM: Okay. On behalf of the

21 airline?

22 MR. LUTCHMEDIAL: No. Well, on behalf

23 of the state.

24 MS. GRAHAM: Behalf of the state,

25 okay.

Page 49

1 MR. LUTCHMEDIAL: Because the state

2 will not allow a foreign MRO to do maintenance on

3 a \-- the same way the FAA will now allow an MRO

4 in Abu Dhabi to do \-- unless they have an FAA

5 repair station.

6 MS. GRAHAM: Okay. Any other thoughts

7 on that question?

8 MR. WAKE: I believe there are two

9 types of MRO services. There are airlines who

10 have capacity to do their own and a bit extra to

11 do for others. And the primary service that they

12 would want to give is to themselves, and any

13 extra time, they would want to sell it to others.

14 With that type of an attitude, I think it will be

15 very, very difficult to give a very good service

16 to the third \-- to the other carrier.

17 I think as Ramesh indicated, one,

18 before any maintenance service is outsourced to

19 any other organization, the civil aviation will

20 have to evaluate. More than the civil aviation,

21 the airline that gives out that service would

22 also have to check thoroughly if it meets their

23 requirement. And they would also have to have

24 information from other organizations that use

25 other MRO service before them, because civil

Page 50

1 aviation may look at other relation but may not

2 get other details. So their own technicians will

3 have to check thoroughly what that MRO does, and

4 also there must be a service level element

5 between the MRO organization and the airline that

6 your outsourcing that maintenance work.

7 MS. GRAHAM: Okay. So Kim Choon said

8 done assume that the third party would have any

9 worse capability than you do. In fact, it could

10 be very much better. In your case, make sure you

11 get a performance agreement and do your due

12 diligence. Okay. Another question? Please,

13 third row. If you would, please stand up and

14 identify yourself and it\'s tough to see from

15 here.

16 MR. MILLAM: I\'m Mark Millam from

17 Northwest Airlines. Just would like to, if I

18 could, push a little bit harder on a question the

19 moderator brought up about measuring culture.

20 Remember the reason, I think, we all believe that

21 culture is so important is we\'re aiming for

22 something that is a really high target, is trying

23 to have several years in a row for all of our

24 organizations in avoiding accidents and

25 incidents. So the culture really plays a big

Page 51

1 part of trying to produce that sort of safety

2 record and it kind of calls into question whether

3 or not you can really use safety metrics by

4 themselves, you know, measure what your safety

5 culture is.

6 So you touched a little bit on, you

7 know, should you do some surveys, and I am just

8 curious knowing that within our airline, we\'ve

9 got safety metrics. We measure them all the

10 time. We\'re aiming for zero NTSB accidents and

11 incidents all the time. Sometimes we hit them,

12 but when it comes down to it, every so often, we

13 keep hearing feedback and perceptions and from

14 line people that say, you know, what our managers

15 really want is a on-time departure more so than

16 they want to check on safety.

17 So is this really something that we

18 can effectively, measure what the organization\'s

19 culture is? I liked Steve\'s comment about, you

20 know, you got a safety culture. It may not be

21 what you want, but we all have it. It\'s just how

22 do we really, really measure it?

23 DR. PREDMORE: Yes, I mean I don\'t

24 think there\'s a single measure obviously. I

25 think it is a combination of asking people,

Page 52

1 surveying, you know, a broad spectrum of various

2 performance metrics, whether there\'s the safety

3 performance or overall operational performance.

4 Because then I believe steadfastly that, you

5 know, there\'s a direct correlation between

6 operational performance and safety performance,

7 because humans are behind both. So I think, you

8 know, if you just focus on the safety statistics,

9 you may miss some things that ultimately will

10 appear there, but you can head off early and vice

11 versa with operational.

12 So it\'s operational metrics, it\'s

13 safety metrics, it\'s asking people and surveying

14 people. You know, as an industry, we\'ve

15 developed with a lot of tools over the course of

16 the last 10 or 15 years that, I think, all of us

17 wonder what we did without \-- FOQA data, flight

18 data monitoring systems, programs like ASAP and

19 other reporting systems, LOSA, a hugely valuable

20 tool. So I think you try to hit it from sort of

21 all levels, and maybe you never assume that

22 you\'ve got all the data. I don\'t know. It\'s a

23 great question. I mean it\'s the holy grail.

24 I know my boss is always asking me,

25 you know, how do you know whether we\'re riskier

Page 53

1 today than we were yesterday, and I really want

2 you to be able to walk in here and tell me. You

3 know, I\'d love to be able to do that, but \--

4 MS. GRAHAM: I\'ll take off my

5 moderator hat for a moment, and I\'d like to

6 answer that question from the point of view of a

7 woman. I think management is as much an art as

8 it is a science, but I think you can feel a

9 safety culture. And as you said, when you walk

10 into an organization, one of the things that

11 comforts you is to see a board of directors and a

12 commitment to a particular management style or a

13 particular code of ethics.

14 When I go into a facility and I see

15 data on the wall, with trend data on the wall, I

16 think you can feel a safety culture. I think you

17 can feel when people are open, and I don\'t think

18 it\'s necessarily always data driven although I

19 think that\'s very important, but I think you can

20 feel it And for m, I think that\'s very important

21 \-- how open people are about everything, because

22 it\'s not just open about safety but closed about

23 \-- it\'s really a question of openness and

24 willingness and I think you\'d have to sort of

25 feel that. You were going to say?

Page 54

1 MR. GROSSMAN: Yes, I think you can

2 measure it. You just can\'t measure yourself. If

3 you expect people to open up about what the

4 culture is, I think you almost need to bring

5 somebody in from the outside that they can trust,

6 etcetera. So I think that\'s part of the

7 challenge. And then I also think you can look

8 internally, and if you want to look for signs,

9 what is that station manager or supervisor, how

10 is that person rewarded. Are they rewarded by

11 the percentage of on-time departures or is it

12 some combination of on-time departures, lack of

13 accidents, etcetera. If it\'s just on-time

14 departures, then you can almost guarantee that\'s

15 what they\'re going to push. And so that can

16 generate the reverse case of a safety

17 environment.

18 MS. GRAHAM: Anybody else want to

19 comment on that?

20 MR. WAKE: Okay. I think when you

21 introduce a KPI for any office, that KPI should

22 also include safety. And if you have a balanced

23 core type of evaluation, I think you have to make

24 sure that safety is in it. But the formal way of

25 checking would have to be there. But I think

Page 55

1 there should also be an informal way of checking

2 \-- talking to pilots, talking to customers,

3 talking to people around the facility, and also

4 looking around. If you see people are throwing

5 anything around the airport, that can be an item

6 at a later point. So if it is kept cleanly, it

7 can give you an indication that it is working.

8 But talking to people, I think you\'ll get

9 information. Informally talking to people, you

10 will get an information that you never get

11 probably through the normal channels.

12 MS. GRAHAM: So figure out what\'s

13 happening by the water cooler. Okay. Okay, I

14 see another question in the back, in the middle.

15 MR. HOLLINGER: This is Kent Hollinger

16 with MITRE. Nancy, you opened yourself up by

17 taking off your moderator hat, so I got a

18 question for you.

19 MS. GRAHAM: Okay.

20 MR. HOLLINGER: Steve mentioned

21 earlier that he thought a good indication of a

22 safety culture is reporting. And I\'ll probably

23 take that even further. It\'s when it\'s so

24 ingrained in the culture, that people may even

25 fix things without having to report and yet maybe

Page 56

1 report things they can\'t fix themselves. And so

2 as important that is, we\'ve got a lot of places

3 in the world yet where that\'s going to be even

4 harder than other places. There\'s going to be a

5 lot of fear of reporting, maybe even legislative

6 and other types of punishments.

7 Is there anything that ICAO can do to

8 help in that, and if so, is there anything

9 underway already to try to help ease that into

10 the other parts of the world?

11 MS. GRAHAM: Now that\'s a great

12 question. I wish I had a magic wand for that. I

13 wish ICAO had the authority to legislate a safety

14 culture and no blame culture, whatever you want

15 to call it. The short answer is, no. The Chicago

16 Convention doesn\'t allow for that. I\'ve already

17 asked. It is really something that each state

18 has the sovereign authority to make a

19 determination about in terms of how they deal

20 with safety information. But it is something

21 that ICAO can promote, and it is something that

22 ICAO can encourage. And we do do that, perhaps

23 not enough. But it\'s not something that ICAO can

24 legislate. I wish it were.

25 More questions? Just one? Oh, Dan \--

Page 57

1 Dan the expert. Help em out Dan.

2 CAPTAIN MAURINO: That statement is in

3 the eyes of the beholder. I\'d like to go \--

4 MS. GRAHAM: Introduce yourself then.

5 CAPTAIN MAURINO: \-- back to the

6 question for one moment, which I think is

7 important. And I might take a contrasting view

8 here. I\'m positive that you cannot measure

9 safety culture, because you cannot measure a

10 construct. Safety culture doesn\'t exist. It\'s

11 something that we create in our minds. We put a

12 name to it. It\'s sexy. It sells, and therefore

13 we take it. I think that what you can measure

14 are the processes that will deliver the safety

15 performance that you\'re organization expects.

16 And if the measurement of those processes tells

17 you that your organization is where you want your

18 organization to be, then that\'s it. And then all

19 these questions of measuring safety culture

20 become prehistorical.

21 MS. GRAHAM: So that was Captain Dan

22 Maurino who you heard from this morning, one of

23 the world\'s most foremost experts on SMS saying,

24 no, you cannot measure a safety culture, no. A

25 resounding no.

Page 58

1 DR. PREDMORE: And just maybe to build

2 on that a little bit. I agree, Dan. I don\'t

3 think you can ever know in absolute terms what

4 your safety, the culture measure is. And I don\'t

5 think as safety professionals we spend a lot of

6 time doing that, because it\'s probably

7 impossible. And I know the question that we ask

8 a lot is are we better today than we were

9 yesterday and what do we have to do, you know,

10 next year, tomorrow, whatever it is to be better

11 than we were today. So it\'s really about sort of

12 relative movement, not kind of where you are.

13 And, you know, you come out with a safety culture

14 measure of 9. What does that mean? So it\'s more

15 about continuous improvement, I think, than it is

16 about absolute safety culture measures.

17 MS. GRAHAM: So I\'m going to ask you

18 a question now. The question was brought up

19 about whether or not ICAO can mandate or

20 legislate a safety culture, no blame culture,

21 whatever you want to call that. My question to

22 you is what can ICAO do to support for you to

23 support the safety culture that we all want? I

24 love it when there\'s not a hand. Isn\'t that

25 great. That means I have no work to do. Okay \--

Page 59

1 one or two.

2 MS. ALSHEHRI: Yes. My name is Saad

3 Alshehri, Captain Saad Alshehri. I work for

4 Saudi Arabian Airlines. I am the Vice President

5 of Safety and Security. I think what ICAO can do

6 in that part is really to help people creating

7 the awareness required and maybe do some

8 financial help in areas where it is required to

9 build that culture. Culture, basically, the way

10 that I understand it, it is the way we do

11 business around here. It is something that you

12 develop yourself. But you can only create the

13 safety culture when you have the basics, the

14 basic elements to produce safety. Once you have

15 the basics and you build the processes, you

16 empower people, you double-size it, and you get

17 somebody to help you if you need help. I think

18 ICAO has been doing a great deal of help,

19 especially regions that require it. And I think

20 we can create this message even further, you

21 know, by creating the awareness required.

22 MS. GRAHAM: Okay. Thank you.

23 Thought I saw another hand to give me a job to

24 do; actually, to give Dan a job to do. What am I

25 saying?

Page 60

1 MR. SMITH: Dave Smith with Midcoast

2 Aviation. I\'d like to see several things. And

3 again, this is a little out of my area of

4 expertise, so it may already be in place, but I\'d

5 like to see some safety culture do\'s and don'ts

6 for managers. We\'ve seen situations where on the

7 ramp, everybody is way behind, the customers want

8 to leave, and we see somebody pushing an airplane

9 at 20 miles and hour. And then we go back and

10 congratulate him for getting everybody out of

11 here before we look at how he did it. You know,

12 geez, how did you move 15 airplanes in 6 minutes?

13 If we look at how they did it, we might then

14 explain to them that they haven\'t followed their

15 procedures, but we jump in and say great job,

16 everybody\'s happy.

17 The other thing is I think, although

18 you cannot get a finite measurement on safety

19 culture, you could get some indicators. How do

20 you find out about incidents? Do you find out

21 through the channels that they\'re supposed to?

22 Hopefully, you have procedures. Culture could be

23 measured by whether we\'re following those

24 procedures, and that would be determined by how

25 you find out we didn\'t follow them. If it

Page 61

1 results in an accident, there were probably some

2 indicators we were never aware of, the culture

3 isn\'t where it needs to be.

4 If we start getting those indicators,

5 as was mentioned, that there are some near misses

6 and things along those lines, then before we have

7 an accident \-- now if we don\'t do anything about

8 that, shame on us \-- but those are indicators

9 that we have the safety culture that we\'re

10 looking for because of the reports that are

11 coming in. So I\'d like to see some ideas on do\'s

12 and don'ts, how much damage does it do when you

13 congratulate somebody for doing a job because

14 they stretch the procedures a little bit, those

15 types of things, because I think we\'ve got a lot

16 of people that are really trying to do a great

17 job and don\'t know how to do it. They don\'t

18 realize the damage they do when they give

19 somebody kudos for doing something that is beyond

20 their procedures.

21 DR. PREDMORE: Well, I think as

22 somebody else said, that\'s not typically what

23 they\'re held accountable to. Usually, they\'re

24 held accountable to an on-time performance or \--

25 MR. SMITH: Yes, exactly. If it was

Page 62

1 part of the performance review and so on, that

2 might help bring it to their attention, but if

3 they don\'t have the education as to what the

4 implications are of congratulating somebody for

5 satisfied customers or whatever, they may still

6 fail in the performance review without even

7 knowing what they did. And I think that\'s the

8 biggest single problem.

9 MS. GRAHAM: So be careful why we hand

10 you a reward, because that\'s, in fact, what\'s

11 going to get repeated. I think we can help you

12 with that. See Dan afterward. He can help you

13 with some \-- I know that we some do\'s and

14 don'ts, so he can help you with that. Anybody

15 else, other questions, other issues? I see one

16 way in the back. Usually, the one way in the

17 back is the hardest.

18 MR. DJIBO: My name is Boubacar Djibo.

19 I am from \--

20 MS. GRAHAM: Can\'t hear you. We can\'t

21 hear you.

22 MR. DJIBO: \-- the African Civil

23 Aviation Commission.

24 MS. GRAHAM: Sorry. We can\'t hear

25 you. Could you start over?

Page 63

1 MR. DJIBO: Yes. I am Boubacar Djibo

2 from the African Civil Aviation Commission. I am

3 quite comfortable and I quite agree with what Dan

4 said. What\'s the issue with safety culture?

5 What is the added value? We\'re discussing about

6 culture, but my first question will be to you.

7 As an ICAO Director, from the statistics, the

8 data you have collected, have you ever found a

9 link between the rate of accident and the lack of

10 culture of safety? It\'s interesting because for

11 me, what is important \-- because we have listened

12 to a lot of data, statistics \-- the important

13 thing for us with the lack of competencies, the

14 lack of training, the lack of regulations from

15 the regulators first, if we have a lot of

16 accidents or incidents in the country, maybe then

17 the lack of those things, human factors maybe \--

18 but when you talk about culture, I\'m a little bit

19 confused. And that\'s why I was happy with your

20 intervention.

21 Can we really find a link, create a

22 link between culture and safety. If you assume

23 that everyone is following what is agreed upon in

24 ICAO, that people are well-trained, are paid, are

25 really managed just like other organizations,

Page 64

1 will we continue to talk about lack of safety

2 culture? Thank you.

3 MS. GRAHAM: I told you the ones in

4 the back of the room are always the hardest.

5 Well, I give you my thoughts and then perhaps

6 others would like to chime in. There is a direct

7 correlation between a lack of candor and a lack

8 of willingness to report and safety incidents.

9 Okay? There\'s a direct correlation there. So

10 whether you want to call that culture or whatever

11 you want to call that, the more open the

12 environment, the earlier you get earlier

13 reporting, the better you are able to manage

14 earlier interventions.

15 So whatever you want to call that, if

16 you call that an open culture, whatever you want

17 to call that, that\'s what works. There\'s never,

18 to my knowledge \-- Dan, you\'d have to tell me,

19 but I don\'t think there\'s ever been any work that

20 ICAO\'s done in terms of quantifying culture, has

21 there? Dan\'s going to tell us. I don\'t think

22 so.

23 MR. DJIBO: Thank you.

24 CAPTAIN MAURINO: Well, as some of you

25 probably know, around the mid-90\'s, 1995 or so,

Page 65

1 culture became the flavor of the month in terms

2 of aviation safety. And this was under the

3 umbrella of human factors, so we did get

4 involved. ICAO did get involved in that

5 particular topic. There\'s absolutely no way \--

6 we found absolutely no way, no proof, nothing

7 that could directly or indirectly relate

8 particular cultural traits and safety or lack

9 thereof. There is none, none.

10 MS. GRAHAM: Anybody else have any

11 thoughts on that?

12 DR. PREDMORE: Well, maybe I can just

13 \-- and maybe I misunderstood the question. But

14 if the question was, you know, we know there\'s a

15 correlation maybe between lack of training and

16 lack of equipment and lack of other resources,

17 relationship between that and safety record, you

18 know, versus culture. But I would say that is

19 the culture.

20 I mean if you\'ve got an organization

21 that is putting unqualified or untrained or

22 inadequately qualified, inadequately trained, you

23 know, personnel out there, that speaks very

24 loudly as to what the culture is and the types of

25 decisions being made. So, you know, I think when

Page 66

1 we think culture, we have to broaden it beyond

2 attitudes and employee satisfaction surveys and

3 other things and really \-- I mean it\'s much more

4 encompassing, I think, than that.

5 MR. LUTCHMEDIAL: Hold on.

6 MS. GRAHAM: Please, go ahead.

7 MR. LUTCHMEDIAL: Yes. I would like

8 to say that, in my view, there is a direct

9 correlation between incidents and accidents and a

10 safety culture. An organization that has a

11 healthy safety culture, you will probably see a

12 reduction in incidents and accidents. As I said

13 before, having a safety program is not having a

14 safety culture, because safety culture is all

15 about attitude. As Captain Maurino said, it\'s

16 all in the mind. It\'s attitude.

17 And therefore, organizations that want

18 to reduce incidents and accidents need to develop

19 a collective, not only an attitude that prevails

20 with a small group of individuals but something

21 that prevails throughout the organization from

22 the very top, from the board, from the CEO down

23 to the person that cleans the floors, as I said

24 before, in order to be able to have a health

25 safety culture.

Page 67

1 MS. GRAHAM: Okay. Another question?

2 It\'s from the back again. Oh, oh.

3 MR. MERCKX: I\'m sorry, Nancy. Erik

4 Merckx from EUROCONTROL. I\'d like to, first of

5 all, come back to the measurement of safety

6 culture. I tend to disagree with Dan. I think

7 one can measure it. So we have, within our

8 organization, developed a methodology which we\'ve

9 tried out at a number of air navigation service

10 providers. It\'s based on a survey interviewing

11 people across the organization from air traffic

12 controllers, with supervisors, managers, senior

13 managers and the CEO. And the first conclusion

14 from that work is people normally are quite

15 prepared to talk openly issues if there are, so I

16 think people are honest.

17 And secondly, you do get a measurement

18 out of it. So I do not agree entirely that

19 safety culture cannot be measured, because it\'s

20 about behaviors. And if people are not behaving

21 properly, there\'s not going to be good SMS and

22 they\'re not going to follow regulations,

23 etcetera. So I think that\'s the basis.

24 And Nancy, to answer your question on

25 what ICAO could do in terms of helping us all,

Page 68

1 there might be a few things. I think that we

2 have already seen today that in quite a number of

3 countries, the national judicial system or the

4 aviation law for that matter actually penalizes

5 people who report incidents. Perhaps from the

6 use of audits, you could extract that information

7 and see how many countries have a judicial system

8 which actually does not promote reporting by

9 controllers, by pilots, by technicians. I think

10 that\'s something perhaps ICAO could do, because

11 they have all the data.

12 Secondly, I think you could perhaps

13 bring the international aviation community

14 together and perhaps work out together with us a

15 number of guidelines how we, within our states,

16 actually can talk to our national judicial

17 experts, the lawyers, the ministers of justice on

18 how we can change the situation in the states. I

19 think we need to do it on a global level. We\'re

20 trying to do it in Europe together with the

21 European Commission, but we\'re not getting very

22 far so far. And I think we need the global

23 voice in order to make it happen. Thank you.

24 MS. GRAHAM: So, Erik, if I understand

25 you correctly, it would be something like a do a

Page 69

1 bit of data mining and develop a briefing that

2 has an ICAO stamp on it that one could use to

3 influence their legislators in a particular

4 state, yes? Okay. I wrote it down. Any other

5 questions?

6 MR. MICHAELIS: Yes, ma\'am. I\'m Mike

7 Michaelis. I\'m the Chairman of the National

8 Safety Committee for the Allied Pilots

9 Association. I would agree with the right

10 honorable gentleman back there that there has to

11 be a methodology to assess a safety culture. If

12 you don\'t have any kind of safety culture or

13 there is a poor safety culture, it doesn\'t matter

14 if you\'re doing mismanagement, FOQA, whatever,

15 it\'s not going to work.

16 When you have reporting taken up to

17 the highest level in the industry, the highest

18 level in the corporation and you report the

19 problems and there is no response back, you kill

20 the safety non-deadly that process culture. And

21 that process needs to be set in place and an

22 assessment needs to be set across the industry

23 globally, and we need to determine how to do

24 that. It\'s not data. It\'s a human factors

25 process, and therefore you can\'t plug it into

Page 70

1 your computer. You\'re going to have to get out

2 and ask people. You\'re going to have to find out

3 how it works, and you\'re going to have to find

4 out what is creating a problem for us in this

5 environment. And if we don\'t do that, then all

6 the good tools and the gold methodologies are not

7 going to do us any good. Thank you.

8 MS. GRAHAM: Thank you for that. I

9 think we probably would all very much agree with

10 you. And that\'s kind of what I meant by I think

11 you can feel it. I think it becomes very

12 evident. You\'re absolutely right.

13 MR. LIN: Right. I think we can feel

14 it and I believe we can measure it. Yes, well,

15 for answers, the question in my mind is what

16 constitutes a safety culture, and what are the

17 appropriate measurements that we can put in place

18 that would then adequately tell us that we\'re

19 measuring the right things.

20 Right now what we have are largely

21 safety management systems or proxies for safety

22 culture which we think are sufficient for us to

23 indicate to us that we have a positive safety

24 culture, although at times, whether you have a

25 positive safety culture requires you to do

Page 71

1 measurements in other arenas, like the

2 operational arena, as well as the HR, the

3 training arena as well.

4 So I think we can measure but I\'m just

5 not sure we are clear what constitutes a safety

6 culture, what are the parameters of safety

7 culture.

8 MS. GRAHAM: Well, as you can see,

9 that is a hotly debated topic. We are running

10 out of time but I would like to take the

11 opportunity to thank a great panel here, a very

12 interesting and, to some extent, provocative

13 discussion. I thank you for that. I thank you

14 for your candor. I thank you for your questions.

15 And if you would join with me in thanking them

16 for their participation.

17 (Applause.)

18 MS. GRAHAM: Thanks very much.

19 MR. WALLACE: Let me just add my note

20 of thanks to that. And I just want to add one

21 quick comment about this, the importance of

22 safety culture reporting. Just it\'s interesting

23 how people are focused on whether you have, you

24 know, kind of a precise mathematical proof to

25 things. And I would just add that in a recent

Page 72

1 compelling example in our experience in the

2 United States, is the worst aviation accident

3 we\'ve had in recent years is the ComAir Lexington

4 departure on the wrong runway, and we did a very

5 extensive mining of data, thousands and thousands

6 of data points, and discovered that there

7 actually had been 117 incidents we could find of

8 similar sort of loss of situational awareness on

9 the surface of the airport. And so you say,

10 well, I don\'t know what that says mathematically,

11 but what it tells me very viscerally is that, you

12 know, people were making similar mistakes and

13 whatever was learned from them wasn\'t sufficient

14 to prevent that accident.

15 So Nancy, thank you very much. I

16 apologize for leaving the torpedo mechanic part

17 out of your intro. I just want to ask you one

18 question. Did you ever launch one by mistake?

19 MS. GRAHAM: No.

20 MR. WALLACE: And if you had, would

21 you \--

22 MS. GRAHAM: (Off mic.)

23 MR. WAKE: \-- and if you had, would

24 you have reported it, so?

25 MS. GRAHAM: No.

Page 73

1 (Laughter.)

2 MR. WALLACE: This panel was exactly

3 what I was hoping it would be, I mean in terms of

4 a world perspective from Oakland to Queens to

5 Singapore to Trinidad and Tobago to Ethiopia.

6 And what I heard was a wonderful set of different

7 perspectives and a wonderfully consistent

8 commitment and I just wanted to say please join

9 me in thanking this panel one more time.

10 (Applause.)

11 MR. WALLACE: And two quick logistical

12 announcements. The exhibits are still open until

13 7:00 o\'clock tonight. They\'re downstairs. I

14 encourage you to go see them in the Washington

15 Room, and they will be open tomorrow morning.

16 And cuisine and music of the Americas at 6:45 in

17 the Jeffersonian Room. Thank you all so much.

18 (Applause.)

19 (Whereupon, at 4:47 p.m., the Fourth

20 Annual International Aviation Safety Forum

21 Breakout Panel Debtor session was concluded.)

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