How Aviation Safety Action Program changed the Aviation industry.
Go through stats (Woo!)
Benefits of a non-punitive (non-punishing) culture.
Guide you through OSAP and creating a system where everyone can create a better culture.
Aviation Safety Action Program (ASAP):
“The whole premise behind the ACSF-ASAP is determining the root cause of errors and mistakes without the fear of retribution from the company or FAA”
-Air Charter Safety Foundation president Bryan Burns.
The Short Story: The Federal Aviation Association (FAA) implemented the Aviation Safety Action Program (ASAP) in 1997. Since then they have seen a heavy and sustained decrease in overall airliner accidents, with a significant increase in the number of passengers carried (+593 Million). The ASAP program reduces accidents by encouraging the voluntary reporting of safety issues, while building a non-punitive (non-punishing) culture that attacks the imperfect process and not the imperfect human who will continue to make mistakes. Figure 1 below shows the sustained decrease in incidents that occurred after the implementation of ASAP in 1997, with the dramatic increase in flights shown in Figure 2.
Figure 1. Number of Airliner Accidents Vs Year (1980-2019). https://aviation-safety.net/statistics/
Figure 2. Number of Passengers Carried (Millions) Vs Year (1970-2019). https://data.worldbank.org/
90 percent of ASAP reports are “sole-source” meaning that if the individual responsible does not submit the incident, there will no any awareness of the issue. How can a company encourage self-reporting errors? The Federal Aviation Administration (FAA) grants immunity from punishment when individuals submit reports for unintentional or inadvertent mistakes or even potential mistakes (i.e. they didn’t make the error – they caught themselves before doing so). This “non-punitive” culture and associated concepts have been proven to increase the quality of submissions, and reduce incidents.
Note: All “mistakes” that grant immunity are considered unintentional. In the case of intentional disregard for safety, there is no protection.
Punitive Culture Incident Timeline (Traditional Method):
A mistake is made (or almost made) and either of the follow result.
1) No visible consequences, nothing is reported.
a) Individual does not disclose mistake due to fear of discipline / termination.
b) Lessons are not learned or recorded.
2) Visible consequences, reporting / investigation ensues.
a) Individual is disciplined, possibly terminated.
b) Lessons are recorded.
i) * often implementation or communication is difficult / foregone.
The Non-Punitive Timeline (ASAP Method):
A mistake is made (or almost made) and either of the following result.
1) The individual self-reports.
a) The individual is rewarded and noticed for reporting.
b) The system is altered to prevent the error from being made in the future.
i) Lessons learned is now integrated into the system and errors systematically prevented, meaning that each individual employee is not required to learn that specific lessons; it has already been assimilated.
2) The individual does not self-report
* Less likely to occur due to reward system for reporting.
a) Consequences are visible
i) The individual is encouraged to report in the future and can be disciplined for failure to report.
ii) The individual is not disciplined for the error (again, the errors must be unintentional), focus is on the system not the person.
b) Consequences are not visible
i) Unknown / unseen, cannot be recorded or learned from but is less likely due to reward system for reporting.
ASAP reporting works through the FAA’s website where an employee can access it and submit a report. The report is then received by an Event Review Committee (ERC) for their specific company consisting of three members, normally comprised of an FAA member, union representative, and airline company representative. Each event is reviewed by the ERC who in turn leaves comments and recommendations. The ERC meetings are beneficial for many reasons. One being that employees feel they have a voice and can be rewarded for bringing about issues or even good cost saving ideas. The reviews create great discussion about how best to handle process and improve it to protect others and save money.
The top three reasons for airliners joining an FAA ASAP program:
Continuous improvement and protections.
Gain insights from shared knowledge.
Helps the entire industry become safer and more reliable.
Your next question is: With this public data proving ASAP works, why doesn’t every company try to recreate it?
The program requires leadership buy-in, often a culture-change, and patience to fully implement. As pioneers of the program, the FAA did not see major changes/ results for years. It is difficult to convince employees that if they tell on themselves for making mistakes, there will not be consequences or terminations. The FAA’s guidelines for setting up an ASAP program repeatedly express the need for consistent support from upper management. Without leader promotion and buy-in, the system can fail due to a single negative response to a self-reported incident. Leadership must be prepared to reward those who report their own mistakes, and it is imperative that leadership go as far as to promote and positively publicize the reporting of self-made mistakes.
Oilfield Safety Action Program (OSAP)
With this data in hand, it is hard to ignore that we could do so much better for our people in regards to safety. The industry demands less injuries and downtime. As energy companies there is a need to come together and share knowledge to keep improving.
Steps to implementing OSAP:
Gain Leadership buy-in. Every individual in leadership or management positions related to operations must be fully aware of the mentality required in order to make this program roll-out successful.
Trial the program at one site (rig, plant, or facility).
a. Interview and survey operations personnel. Note their difficulties in the workplace, frustrations, and current needs.
b. Bring employee awareness of the OSAP system, as a potential solution to the problem, empowering them to list their mistakes in order to point out systematic issues that cause the mistakes (rather than placing blame on the individual).
c. Empowerment of employees is key; implementing the program with their direction and buy-in will encourage them to use it well.
d. Explain the program structure to employees, including the benefits and rewards of participating.
e. Refine the software and app to meet specific company needs.
3. Review the results and alter implementation practices as necessary.
4. Have Patience.
We all recognize the need for improved safety systems in the aviation industry – none of us want to hear about planes crashing, or much worse, be on one of them. The FAA realized they needed to do something different to minimize safety incidents and protect the public; so they created ASAP that significantly reduced incidents and changed the culture.
At R-14 Apps we want to build a similar program for the Oil and Gas industry, then any other industry where people can better be protected. We hate injury and death, and it is our vision to live in a world where we know we are doing our best to protect life.
Learn more at our website R14apps.com, call or email us to ask about the program.