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punitive action and attempts to define the line between acceptable and unacceptable actions or
activities.
4.5.36 Table 4-1 summarizes three corporate responses to safety issues that range from a poor safety
culture, through the indifferent (or bureaucratic) approach (which only meets minimum acceptable
requirements), to the ideal positive safety culture.
4-16 Safety Management Manual (SMM)
Table 4-1. Characteristics of different safety cultures
Safety Culture:
Characteristics
Poor
Bureaucratic
Positive
Hazard information is: Suppressed Ignored Actively sought
Safety messengers are:
Discouraged or
punished
Tolerated Trained and
encouraged
Responsibility for safety
is:
Avoided Fragmented Shared
Dissemination of safety
information is:
Discouraged Allowed but
discouraged
Rewarded
Failures lead to: Cover-ups Local fixes Inquiries and
systemic reform
New ideas are: Crushed Considered as new
problems (not
opportunities)
Welcomed
Blame and punishment
4.5.37 Once an investigation has identified the cause of an occurrence, it is usually evident who
“caused” the event. Traditionally, blame (and punishment) could then be assigned. While the legal
environments vary widely between States, many States still focus their investigations on determining blame
and apportioning liability. For them, punishment remains a principal safety tool.
4.5.38 Philosophically, punishment is appealing from several points of view, such as:
a) seeking retribution for a breach of trust;
b) protecting society from repeat offenders;
c) altering individual behaviour; and
d) setting an example for others.
4.5.39 Punishment may have a role to play where people intentionally contravene the “rules”.
Arguably, such sanctions may deter the perpetrator of the violation (or others in similar circumstances).
4.5.40 If an accident was the result of an error in judgement or technique, it is almost impossible to
effectively punish for that error. Changes could be made in selection or training processes, or the system
could be made more tolerant of such errors. If punishment is selected in such cases, two outcomes are
almost certain. Firstly, no further reports will be received of such errors. Secondly, since nothing has been
done to change the situation, the same accident could be expected again.
Chapter 4. Understanding Safety 4-17
4.5.41 Perhaps society needs to use punishment in order to mete out justice. However, the global
experience suggests that punishment has little, if any, systemic value on safety. Except in wilful cases of
negligent behaviour with deliberate violations of the norms, punishment serves little purpose from a safety
perspective.
4.5.42 In much of the international aviation community, a more enlightened view of the role of
punishment is emerging. In part, this parallels a growing understanding of the causes of human errors (as
opposed to violations). Errors are now being viewed as the results of some situation or circumstance, not
necessarily the causes of them. As a result, managers are beginning to seek out the unsafe conditions that
facilitate such errors. They are beginning to find that the systematic identification of organizational
weaknesses and safety deficiencies pays a much higher dividend for safety management than punishing
individuals. (That is not to say that these enlightened organizations are not required to take action against
individuals who fail to improve after counselling and/or extra training.)
4.5.43 While many aviation operations are taking this positive approach to the management of safety,
others have been slow to adopt and implement effective “non-punitive policies”. Others have been slow to
extend their non-punitive policies on a corporate-wide basis. (See comments in 4.5.35 d) regarding a just
culture.)
4.6 HUMAN ERROR
4.6.1 Human error is cited as being a causal or contributing factor in the majority of aviation
occurrences. All too often competent personnel commit errors, although clearly they did not plan to have an
accident. Errors are not some type of aberrant behaviour; they are a natural bi-product of virtually all human
endeavours. Error must be accepted as a normal component of any system where humans and technology
interact. “To err is human.”
4.6.2 The factors discussed in 4.5 create the context in which humans commit errors. Given the rough
interfaces of the aviation system (as depicted in the SHEL model), the scope for human errors in aviation is
enormous. Understanding how normal people commit errors is fundamental to safety management. Only
then can effective measures be implemented to minimize the effects of human errors on safety.
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Safety Management Manual (SMM) 安全管理手册(33)
