In his poem An Essay on Criticism Alexander Pope gave us some very profound statements about human beings. ‘A little learning is a dangerous thing,’ ‘Fools rush in where angels fear to tread,’ and of course my personal favourite, ‘To err is human, to forgive divine’. From a safety perspective, I would add ‘to repeat mistakes is preventable’.
At Air Canada our mantra is ‘continuous improvement’ and our Airports Safety Team is well informed, intensely curious and dedicated to improving our safety culture. In 2007, our team began embracing the study of ‘human factors’ – or how the interaction of the job, the individual and the organization can affect health and safety-related behaviors. By 2011 human factors were an integral part of our safety analysis strategy, and today we have a large group of investigators trained in human factors and the application of nano-codes.
Our organization has greatly benefited and as we become more educated and adept we continue to modify and improve how we apply the study and the codes. For instance we have found that when we review investigation reports we sometimes find nano-codes have been applied based on personal feelings or subjective interpretation and the value and accuracy of the conclusions we draw based on their application is inconsistent. We now believe that having too many coders – or too many chefs in the kitchen – is preventing us from fully benefiting from the trend analysis nano-codes can provide and as a result, we are considering consolidating some of our coding.
Over the years we have compiled a significant amount of data from our investigations and this is enabling us to properly direct our corrective actions and better support safety programmes. For example, we had a few incidents involving ULD loaders. At first glance it appeared that the incidents were randomly spread throughout our work population with little difference between our new and experienced employees.
However, when we dug deeper into our nano-codes we found to our surprise that the newer, less experienced employees were engaged in ‘violations’, while the more experienced employees were making ‘skill based errors’.
In essence our ‘newbies’ had been trained and were aware of the standard operating procedures but failed to follow the procedures because of distractions, a lack of confidence or a perceived pressure to do things more quickly than actually necessary. The more experienced employees were far more likely to simply make mistakes like forgetting steps. From this additional information we were able to better understand our employees’ different behaviors and put in place specific action plans for each group. We reinforced recurrent training for our experienced employees, ran more frequent task-based audits, implemented awareness campaigns and engaged employees through safety briefings. For newer employees, violations were dealt with by removing the employees from the ULD equipment until they gain more experience and receive additional certification.
Storing, auditing and analyzing the enormous amounts of safety data that we collect is both daunting and technologically challenging and we would be lost without our Safety Information Management System – or SIMS, as we like to call it. This key piece of technology underpins the full array of our safety programmes and it allows us to effectively analyze all aspects of our safety reporting.
Thanks to SIMS, we can identify and focus on new systematic issues while connecting all of our investigating, auditing, risk assessment activities to understand the bigger picture. Through SIMS we have been able to develop a risk registry which clearly identifies the top hazards for each work location and region both for the Airports branch and for the entire company.
My safety team enthusiastically gathered and analyzed mountains of data to present me with reports, charts and presentations filled with risks, hazards, trends, occurrences, complaints, audit findings… you name it. I think I may have broken their hearts when I asked them to simply drill it all down to the top three risks each from a quality and an OSH perspective and then prepare plans to deal with them. I am not a big believer in attempting to boil the ocean and wanted to ensure that all the work at the front end would result in concrete benefits for our employees and our organization.
Through Human Factors and SIMS we have accurately identified and targeted our highest risks and made significant advancements in support of our ever-evolving safety culture at Air Canada Airports. Who ever said ‘A little learning is a dangerous thing’?