Assessing Safety Culture within a Flight Training Organization

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Department of Applied Aviation Sciences - Daytona Beach College of Aviation 2013 Assessing Safety Culture within a Flight Training Organization David Freiwald Embry Riddle Aeronautical University - Daytona
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Department of Applied Aviation Sciences - Daytona Beach College of Aviation 2013 Assessing Safety Culture within a Flight Training Organization David Freiwald Embry Riddle Aeronautical University - Daytona Beach, Carolina Lenz-Anderson Embry Riddle Aeronautical University - Daytona Beach Erik Baker Embry Riddle Aeronautical University - Daytona Beach Follow this and additional works at: Part of the Aerospace Engineering Commons Scholarly Commons Citation Freiwald, D., Lenz-Anderson, C., & Baker, E. (2013). Assessing Safety Culture within a Flight Training Organization. Journal of Aviation/Aerospace Education and Research, 22(2). Retrieved from This Article is brought to you for free and open access by the College of Aviation at ERAU Scholarly Commons. It has been accepted for inclusion in Department of Applied Aviation Sciences - Daytona Beach by an authorized administrator of ERAU Scholarly Commons. For more information, please contact Running head: ASSESSING SAFETY CULTURE Assessing Safety Culture within a Flight Training Organization David Freiwald, Carolina Lenz-Anderson, and Erik Baker Embry-Riddle Aeronautical University Assessing Safety Culture within a Flight Training Organization 2 ABSTRACT This study was prompted by a string of aircraft hull losses experienced by a multinational, multi-campus flight training organization. A mixed methods study was conducted to study the attitudes and perceptions of the operations and management staff at this flight training organization through the use of a survey instrument previously existing and adapted, in order to ensure validity, and interviews with key staff members. Confirmatory factor analysis was performed to identify underlying constructs in the perceptions and attitudes of the staff in order to identify beliefs that may signify a flight training organization is at risk. An analysis was conducted using these constructs, along with the interviews obtained from key individuals, to further understand the beliefs, attitudes, and perceptions that may place similar flight training organizations at risk. The research study identifies a lack of a safety culture throughout the organization. The current system is substantially reliant on the necessity of flight instructors and their students to maintain a clean record in order to be viable for future employment and is seen by this operator as the primary system for ensuring accountable action by agents within the system. The implementation of a Safety Management System is recommended as a result of this study. Assessing Safety Culture within a Flight Training Organization 3 Assessing Safety Culture within a Flight Training Organization In 2011, the two United States campuses of a multinational flight training organization experienced a high number of operational aircraft accidents and incidents, including four fatalities in two separate accidents and a net loss of five airframes. In a fifteen-month period between April of 2010 and July of 2011, 25,696 hours were flown while the company suffered two fatal accidents, a total of five hull losses, four engine fires, and twenty-seven pilot-induced incidents that required unscheduled maintenance (G. Austin, personal communication, November 4, 2011). All of the accidents involved students on solo flights or rentals. During the same period, the United Kingdom campuses of the same organization did not have any accidents or incidents. At present the organization does not employ a Safety Management System (SMS) or any other proactive system beyond a nominal quality assurance program. Even in the dynamic environment of high-tempo flight training this rate of occurrence is notable. More importantly, this rate of occurrence is both economically and socially unsustainable and requires intervention (Strauch, 2004). Because these events appear to occur in serial isolation to each other, there is no systemic analysis as to the root cause or causes that may underlie the events. In a flight training organization it is the instructors who are not only the means of production but also tasked with inculcating values, particularly safety values, into their students. It is a peculiar aspect of aviation instruction in the United States Assessing Safety Culture within a Flight Training Organization 4 that the majority of instructors are not seasoned careerists but are often a year or less removed from the experience level of their new students (Aircraft Owners and Pilots Association, 2010). Many often see instructional careers as a steppingstone to an airline cockpit, and economic forces further affect this with an inverse relationship between instructor experience and economic conditions. This yields a condition where accession to the airlines is relatively quick, and the greatest numbers of young pilots are being taught by likely the most inexperienced instructor cadre relative to other times. During periods of high turnover, it is expected to see an increase in the number of accidents occurring. This phenomenon is well documented in the literature. What makes this scenario under investigation so troubling is that it is occurring during a period of economic and industry stagnation; there has been very little turnover in the firm s instructional staff in the past two years while the accident and incident rates have steadily increased. What must be considered is that these events, previously considered only in isolation, are indicative of systemic shortcomings when taken collectively, and could possibly be an indication of the lack of an effective safety culture. Literature Review Research studies involving mixed research methods related to safety are often found in the medical arena, and a number of these studies draw parallels to lessons learned in aviation, often pointing out how reporting systems have greatly Assessing Safety Culture within a Flight Training Organization 5 evolved in the aviation industry. Johnson and Terrence (2008) examined the corporate culture of an aviation organization and how that culture and individual intuition influences flight crew safety decision-making in a less-than-optimal, high-workload environment. A quantitative methodology utilizing content analysis and two qualitative approaches, focused and individual interviews, as well as observation was employed in this study. The company utilized for the study was Acme Community Air Service (ACAS), Inc., which provides humanitarian assistance in over 35 different countries. ACAS s operations are most often conducted in foreign nations where crews and staff personnel fly and maintain the aircraft, while living and working in environmentally harsh conditions. To accomplish its mission, ACAS owns, operates, and maintains a number of smaller single and multi-engine aircraft, permitting access to remote areas less conducive to operating larger turbojet aircraft. ACAS has long recognized the need for a strong aviation safety program, and in 1977 began assigning trained safety personnel at the corporate level. The quantitative portion of the Johnson and Terrence study concentrated on analyzing the safety reports submitted primarily by pilots and maintenance personnel. The study concluded that conflicting safety and mission expectations resulted in conducting flight operations in less-than-optimal conditions. Practices, such as requiring its flight staff to perform additional organizational duties, also contributed in varying degrees to individual stress and fatigue. Both stress and fatigue were implicated in poor in-flight decision-making, incidents, and Assessing Safety Culture within a Flight Training Organization 6 accidents. Pilot error was most often the conclusion of ACAS aircraft accident investigators, ignoring the effect of corporate expectations placed on flight crews. ACAS expectations seemed to prioritize production over safety. When ACAS flight crews were faced with decisions surrounding these expectations, ACAS could have anticipated most of its crewmembers would have made choices that placed mission ahead of safety. Biarman, Paletz, Orasanu, and Brooks (2009) examined the direct and indirect pressures that can be exerted on pilots by Alaskan operators. In addition, the paper examined ways in which organizations and individuals manage the effects of pressure. The study built on previous research that utilized a survey instrument that revealed companies with an elevated accident rate are more likely to stress on-time delivery of mail as important to their financial success, and to be less concerned about the effect of scheduling practices on the fatigue levels of their pilots. Twenty-eight pilots who flew in Alaska were recruited, via advertisements, and were interviewed in Anchorage and Fairbanks. Interviewers trained in the critical decision method, and with backgrounds in aviation, conducted interviews to explore weather-related incidents that had challenged the participants skills as a pilot. Based on transcripts of the taped interviews, a set of bottom-up categories was created by identifying types of pressures. This initial scheme was generated in a data-driven fashion. The detailed categories were then clustered into themes based on conceptual similarity. The Biarman et al. study concluded that pilots in Alaska encountered both Assessing Safety Culture within a Flight Training Organization 7 implicit and explicit norms and expectations to fly in marginal conditions. Pressure also arose from pilots awareness of the need for their company to make money and perceived job competition. Some Alaskan operators were able to mitigate the effects of pressure on their pilots; some pilots reported mitigating pressure to fly by managing their employer s expectations and re-emphasizing safety. The traditional aviation safety program has matured into what is now known industry-wide as an SMS. According to Brown (2008), the shortcomings of the traditional programs are their cumbersome focus on the individual components of safety instead of a holistic, big-picture perspective. Traditional programs have focused on reporting and investigating events that have already occurred (Brown, 2008). The new SMS approach involves an entire flight operation (pilots, maintenance, and support personnel) working together to increase aviation safety using a comprehensive systems perspective (Brown, 2008). Brown describes safety as freedom from harm, or the minimization and management of operational risk. Since there will always be hazards and risks involved with aviation, proactive safety management (an SMS) is required to identify and control those hazards, minimizing those risks to effectively manage aviation safety. In his 2001 report, Dutcher looked at the attitudes towards flight safety using the Royal Canadian Air Cadet Gliding Program (RCACGP) as his subject base. He collected 69 returned surveys measuring attitudes towards safety and Assessing Safety Culture within a Flight Training Organization 8 human factors training from instructors and cadets alike. His results showed no statistical difference on those attitudes between instructors and cadets, men and women, or low and high flight time. Not surprisingly, Dutcher s (2001) data showed that the previous involvement in an aviation incident leads to a more positive attitude towards safety training. He drew the conclusion that neither frequency of exposure to human factors training nor the accumulation of flight hours statistically changed participants attitudes about this training for the better (Dutcher, 2001). Dutcher did find that the possession of more advanced pilot licenses did improve the participants perception of the relevancy of the safety training. Dutcher, Carrick, and Smith (2003, p. 4) makes a new realization, measuring personnel attitudes may be a better measure of true flight safety than occurrence rates. His further research on this same subject data led him to recommend simulator training, even low-cost, low-tech simulator types, as a method to further human factor safety techniques. He also finds that personnel errors and attitudes are symptoms that can only be ameliorated by treating the underlying causes (Dutcher et al., 2003, p. 4). According to Dutcher et al., organizations must provide an environment conducive to the development and maintenance of aviation safety (2003, p. 4). They suggest: incidents should be of more concern, viewed as ideal learning opportunities (2003, p. 4). Dutcher et al. s methods involved a questionnaire containing 30 Likert-scale questions on flight safety attitudes, three open-ended questions on satisfaction and general Assessing Safety Culture within a Flight Training Organization 9 perceptions of safety, and a demographic section. He also sent two identical surveys to about ten percent of the participants, who were instructed to return them at least one week apart. Dutcher used this to establish reliability for his test. Dillman, Voges, and Robertson (2007) prepared an 18-question Likert survey to determine the perceptions of aviation students towards voluntary reporting and the potential reasons for failing to file safety occurrence reports at Purdue University and Southern Illinois University Carbondale. Dillman et al. (2007, p. 1) thought that the key ingredient to the success of any safety culture is the need for information about unsafe events, activities, or potentially hazardous operations. On occasion, participants in or witnesses to unsafe or potentially unsafe circumstances fail to communicate the information that is vital to maintaining the continuity of the safety culture (Dillman et al., 2007, p. 1). They found that the primary reasons for not submitting safety occurrence reports were a lack of time, ridicule from others, and embarrassment from peers (Dillman et al., 2007, p. 1). Dillman notices possible reasons for failure to report: fear of punishment, lack of management support, lack of feedback, lack of a safety priority, or a different perception of what is considered safe or unsafe. The survey included Likert-type data as well as open-ended essay responses, but he expressed a desire to go back and obtain qualitative data from interviews with students and instructors to further analyze his research question. Unfortunately, the Likert-data resulted in bell curve data with nothing statistically significant or conclusive. The authors noted that the most interesting responses were from the open-ended Assessing Safety Culture within a Flight Training Organization 10 questions which expressly detailed specific problems that the Likert-questions could not: need for better access to safety reports, a lack of time to fill them out, and potential embarrassment from student peers and instructors. The psychology that impacts a person s desire to learn quietly from their own mistakes is understandable (Dillman et al., 2007, p. 10). Unfortunately, these private moments of self-reflection and maturation do not necessarily contribute to the growth of a flight school in an organizational sense. Research Questions The three research questions that this study investigated were: 1. In a flight training organization with operational deficiencies that have resulted in several accidents, what is the composition of underlying constructs of safety attitudes? 2. How do key individuals within the organization describe the underlying elements? 3. Based on the results, what could be proposed in regards to implementation of a Safety Management System? Method Research Design A mixed methods research design was selected for this study that included quantitative and qualitative data collection and analysis. The research design was an explanatory mixed-methods design (Creswell and Plano Clark, 2010). In this Assessing Safety Culture within a Flight Training Organization 11 mixed methods design, the qualitative data is intended to enhance the understanding of the quantitative data. This type of design was selected to assess trends and relationships with quantitative data and also explain the reasons and constructs behind the resultant trends. This mixed methods study was designed to analyze the safety culture of a flight training organization that had multiple events leading to incidents and accidents. An explanatory sequential mixed methods design was utilized, and it involved collecting quantitative data first and then explaining the quantitative results with in-depth qualitative data. In the quantitative phase of the study, participants completed a survey. Explanatory factor analysis and multiple regression was utilized to analyze and find the constructs that could be important to understand the safety culture of the organization. The qualitative phase was conducted by interviewing participants that are members of the organization. The results of the qualitative part of the study were utilized to explain and confirm the results of the quantitative study. Participants and Sampling Procedures The study participants were drawn from the current employees of the United States and the United Kingdom training locations of the organization being studied. The recruitment of the survey participants was accomplished using convenience sampling of volunteer employees currently employed and able to Assessing Safety Culture within a Flight Training Organization 12 receive at their company address. The participants were also purposively recruited in an attempt to obtain a minimum of ten in each of three categories: flight instructor, management personnel, and support personnel. These participants were then segmented into categorical groups for subsequent analyses by gender, profession, and facility. Responses that were missing data for profession and facility were excluded from further analysis. Instrumentation Quantitative instrumentation. The quantitative portion of the study utilized the Commercial Aviation Safety Survey (CASS) by Wiegmann, Zhang, von Thaden, Sharma, and Mitchell (2002), with only nominal adaptations for a flight-training environment. The CASS was created as a means of measuring the overall safety culture within an airline. Admittedly, the use of survey methods do not yield an equivalent level of detail as other more rigorous strategies, such as individual interviews or direct observation, but they do yield the comparative advantage of allowing a larger amount of the target population to be measured and to do so anonymously and without fear of negative repercussions, particularly given the questions about the nature of the organization. The CASS was designed to measure five organizational indicators of safety culture, previously defined by Wiegmann, von Thaden, Mitchell, Sharma, and Zhang (2003) from reviews of the literature. These indicators from their Assessing Safety Culture within a Flight Training Organization 13 work were synthesized from common themes in safety culture research across multiple fields, inclusive of aviation, and are listed below. Organizational Commitment to Safety: The degree to which upper management promotes safety, as evidenced by safety-related policies and the commitment of resources to maintain and improve safe operations. Managerial Involvement in Safety: The degree to which middle and lowerlevel managers are personally involved in safety activities and in promoting safety among their employees. Employee Empowerment: The degree to which employees are invited to participate in safety-related activities and decisions, and encouraged to take personal responsibility for safety. Accountability System: The degree to which the organization rewards safe behavior and dispenses consequences for unsafe behavior. Reporting System: The degree to which the organization possesses an effective, accessible means of reporting safety information those employees are willing to use. As with Wiegmann et al. s original work (2002), the safety culture survey is comprised of eighty-four items that are grouped as follows: measure
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