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Sponsored by ASEM - IISE/SEMS - CAE- ABEPRO
Error Management - Just Culture in Aviation
If you want to deal with errors you will have to know them first. But do we get all the information that we need? What about those mistakes or mishaps that can be easily hidden because they did not cause any obvious damage and hence remained unnoticed? The question is whether employees share all their experiences voluntarily or do they hide them because they fear retribution?
Unlocking hidden information that cannot be gained by a traditional monitoring system is the key for a successful learning culture. A proactive or even predictive approach requires the involvement of the relevant staff. To achieve this, it is imperative to have an atmosphere of trust in which people are encouraged and feel responsible to provide all essential information in the clear understanding that the company accepts that errors and lapses of judgement may occur and that staff, in the course of their normal, expected duties, do not intentionally commit such errors. The only exceptions to this general non-punitive policy are where the actions or omissions involve negligence, reckless disregard or a failure to report safety incidents or risk exposures.
The Just Culture approach aims to ensure a relationship of trust and an understanding of what is acceptable and unacceptable that is supported by all employees. It provides the key for gaining the information an organization needs to analyze and manage its errors and mistakes.
Moritz Koester is a Flight Safety Officer at a major European airline. He began his career in Aviation in the United States, where he worked as a flight instructor and helped manage flight schools and an aerial imaging business.
Upon his return to Germany, he joined the airline he works for to this day and accumulated over 5500 hours of flight time as first officer on Airbus A320 and A330 aircraft. In addition to his duties as a pilot and flight safety officer, he also contributes as a simulator instructor on the A320. He holds an undergraduate degree in Aviation Business Administration and a Master of Business Administration with a specialization in Aviation Management.
Moritz is committed to supporting the organizations' safety management in the most effective and efficient ways possible, successfully strengthening the safety culture at his organization during his tenure as flight safety officer. The quantity and quality of the information gathered has increased considerably during that time.This webinar is the second in a four-part series.
What happens if someone makes a mistake or takes the wrong decision? The issue here is not intentional misconduct, fraudulent behaviour, gross negligence or large-scale mismanagement, but the little mistakes, errors and poor decisions that occur every single day. Mostly, errors are the result of momentary blackouts, a temporary short circuit in the brain, false impressions, deceptive memories, dots wrongly joined, fragments of conversation that we interpret incorrectly, prejudices, momentary feelings of mental imbalance, disorientation, stress and other disturbances.
What does this mean for larger organizations? From research we know that speaking-up when spotting errors is not the norm in organizations. Mistakes are still associated with shame and embarrassment. Yet factual error management can work and be successful as can be seen by studying high reliability organizations such as aviation, medicine, and the nuclear industry.
In the webinar series on error management we will look into the practices and learnings from these high reliability organizations. Apart from the specifics of the different industries we will reflect on what is necessary to establish an effective open error culture. This includes psychological safety to enable communication across hierarchical levels, a system of error reporting, a leadership culture, where people are empowered to speak up, and how humans interact in complex systems.
The speakers are either researchers or practitioners and provide insights into lessons learned from their field. The series will explore how these learnings may be applied in other organizations.
The webinar series is scheduled as follows. Please note that EACH webinar has its own URL for registration.
June 20 - Introduction to error management (Jan Hagen, ESMT Berlin) - 1:00 PM EDT
Register here: https://www.asem.org/event-2566166
July 11 - Error management and reporting culture in aviation (Thomas Wilpert, Air Berlin) - 1:00 PM EDT
Register here: https://www.asem.org/event-2568371
July 25 - Empowerment as tool for error management in medicine (Jan Brommundt, University Medical Center Groningen) - 1:00 PM EDT
Register here: https://www.asem.org/event-2568393
August 8 - Management practices of learning from errors in high risk industries (Nicolas Dechy, Institut de Radioprotection et de Sûreté Nucléaire) - 1:00 PM EDT
Register here: https://www.asem.org/event-2568621