Safety culture

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Safety culture
Posted by Norm48327 on Wednesday, January 10, 2018 9:55 AM

What  is "Safety Culture" and how would you best explain it and convey the message to your staff?

Ken Hylander was recently appointed Director of Safety at Amtrak. Given that he comes from the airline side of the transportation equation I would ask others if they think he's qualified to impart his thoughts and ideas regarding railroad safety in a manner that will have an impact on the industry. Even the most naive among us railfans know you don't walk in front of a train that is moving, nor too close to one that is stopped.

That said, I started my career in aviation as a "Ramp Rat" and worked my way up from there. The first thing we were told was to never get close to a turning propeller if you want to see your next birthday. Much truth to that, but how does the safety culture in aviation relate to railroading. IMO, it means always being aware of your surroundings and circumstances that may affect you.

Should that culture be implimented from the top down or the bottom up? Do track foremen have an obligation to their employees to enforce safety regulations? I believe so after watching my track foreman correct one of his employees.

Is being safety oriented directly related to the industry in which one is currently working or is it being able to read the big picture?

Norm


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Posted by zugmann on Wednesday, January 10, 2018 9:58 AM

Norm48327
Should that culture be implimented from the top down or the bottom up?

Both and all ways in between.  This stuff will kill you in the blink of an eye.  You can never lose your respect (and fear) for this equipment.

The opinions expressed here represent my own and not those of my employer or any other railroad, company, or person.

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Posted by MidlandMike on Wednesday, January 10, 2018 10:37 AM

The fact that US commercial aviation has not had a passenger fatality in something like 10 years indicates that the airline safety people are doing something right.

Edit: Upon further research it looks like 8 years.

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Posted by Ulrich on Wednesday, January 10, 2018 10:52 AM

There's still lot's of work that needs to be done on the "culture" side, beyond orientation and lip service. I find that a "fast paced" work environment often runs contrary to safe work practices. Probably the single biggest thing an employer can do to improve safety is to control the work pace.. imho it needs to be slow, deliberate, and measured.. not fast paced. In my career most of the accidents I've seen have been due to someone working under unrealistic time pressure and taking shortcuts. "Fast paced" might be fine for a law or accounting office but not so much for a transportation company where lives are at stake. 

 

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Posted by tree68 on Wednesday, January 10, 2018 11:00 AM

Everyone has a responsibility to themselves and to those around them to operate in a safe manner, and to ensure that those around them are operating safely.  That includes the right and the ability to stop an unsafe act.  In the white collar world, they call that empowerment. 

Management has a responsibility to lead by example, and to allow their employees to do what's right, without fear of retribution.  Many industries now have "close call" reporting - an employee needs to know that if they report a close call they won't get in trouble for it.  

A true safety culture will allow that to happen.  People make mistakes, things break.  Knowing one can report a near miss and that management (and everyone, for that matter) will take it as an opportunity to improve, and not punish, is the key.

It's been said, many, many times, that railroad rules are written in blood.  It's interesting that EHH's decree to stop using "three step" was met with a great deal of incredulity.  One can easily believe that even if the words aren't said over the air, that three step is still being used because the employees know it's the "safe route."

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Posted by Norm48327 on Wednesday, January 10, 2018 11:06 AM

Ulrich,

While taking photos of a crossing repair my track foreman friend told (ordered) his crew to stand down while the approaching freight crossed his assigned work area. Everyone followed his order. Engineer did his job of "making noise" until the locomotive was clear of the foreman's protected space.

That was on a single track subdivision with no possibility of opposing traffic.

My question is what do employees on multiple track roads like the Northeast Corridor do. If their boss is not on top of his game and forgets to transfer his protection to the next foreman where does he stand regarding responsibility for any incident/ accident that follows?

It appears that obligations to safeguard employees on Amtrak have been disregarded simpy to get the task accomplished as soon as possible.

My two cents worth/.

Norm


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Posted by Norm48327 on Wednesday, January 10, 2018 11:23 AM

Larry,

Aviators (pilots and others in the industry) seem to have an advantage over railroaders in that respect. Should a pilot or mechanic suspect he has screwed up he can file with NASA an ASRS (Aviation Safety Reporting System) report which is basically a "get out of jail free" card. That information, while confidential  regarding the submitter's name is put into a database so that incidents can be analyzed in hopes of preventing further occurrences of the same ilk.

I believe those who ply the high iron should be offered the same protection if they file such a report in good faith and not be persecuted for doing so.

@jeff hergert,

Is tere any provision for filing such report or are you at the mercy of your employer?

 

Norm


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Posted by BaltACD on Wednesday, January 10, 2018 11:24 AM

Norm48327
Ulrich,

While taking photos of a crossing repair my track foreman friend told (ordered) his crew to stand down while the approaching freight crossed his assigned work area. Everyone followed his order. Engineer did his job of "making noise" until the locomotive was clear of the foreman's protected space.

That was on a single track subdivision with no possibility of opposing traffic.

My question is what do employees on multiple track roads like the Northeast Corridor do. If their boss is not on top of his game and forgets to transfer his protection to the next foreman where does he stand regarding responsibility for any incident/ accident that follows?

It appears that obligations to safeguard employees on Amtrak have been disregarded simpy to get the task accomplished as soon as possible.

My two cents worth/.

What happens on multiple track territory is part of the 'safety culture'.  As can be seen from the Chester incident, for a variety of reasons, multiple failures allowed roadway equipment to be on an active track.

On CSX the 'Flagman' in charge of the Work Zone has all work come to a stop and all personnel in a safe location before authorizing a train to pass on an adjacent track to the one be worked on.

         

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Posted by mudchicken on Wednesday, January 10, 2018 12:10 PM

MidlandMike

The fact that US commercial aviation has not had a passenger fatality in something like 10 years indicates that the airline safety people are doing something right.

Edit: Upon further research it looks like 8 years.

 

You ought to look a little deeper, especially on the employee  side of the issue, on the ground. (OSHA drives the airline whereas FRA drives the rail side of safety. If one side has a rule that the other does not, that rule applies to BOTH)

 

Mudchicken Nothing is worth taking the risk of losing a life over. Come home tonight in the same condition that you left home this morning in. Safety begins with ME.... cinscocom-west
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Posted by selector on Wednesday, January 10, 2018 12:46 PM

Norm48327

What  is "Safety Culture" and how would you best explain it and convey the message to your staff?

...

 

 

The intent, meaning, and practice are entirely dependent on the culture fostered by the senior person, the CEO. In other words, it depends on what impotance is ascribed to safety by the leader of the organization, so it's a leadership problem.

There is a great deal that is 'generalizable' over cultures and workplaces that can be called 'leadership'.  The tone is set by those who seek, identify, and then hire the CEO, and that is probably a Board of Directors.  After the seeking, identifying, and hiring come 'offering feedback', or what is often called 'quality control'.  Where a CEO is held in high regard and left to her own devices, you get what you pay for.  Where a Board is hands-on and vigilant, and offers meaningful feedback to the CEO, you get something else.

It's not quite that simple, though.  No CEO comes into an organization in a vacuum.  He inherits an extant culture, including that of safety.  He inherits morale, states of trust and mutual positive regard between workers at all levels, and he inherits bogus, fraudulent, and unsafe practices and reporting if they exist.

Edgar Schein posited that a culture is a set of assumed values and practices shared amongst members of a group that are meant to foster the aims of that group, even if it's just to co-exist relatively peacefully.  An organizational culture is a group's way of dealing with both external and internal problems, and of finding ways to work in synch and in harmony.  It's a mutual effort, but it gets its resourcing from the top...and that's very important to keep in mind.  If safety is given little shrift, it doesn't take a genius to see that there will be severe problems in a dangerous environment.  If there's little training in safety, poor supervision, limited interest in sanctions for routine infractions, or in observing and taking opportunities to mitigate dangers, the organization is establishing a culture of those approaches to safety.

My own area of study revolved around the internal conflicts that arise in organizations because of a disparity in perceived needs and resourcing to meet those needs.

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Posted by Ulrich on Wednesday, January 10, 2018 12:56 PM

In many organizations safety is "compartmentalized" like.. sales..ops.. marketing etc when it really needs to be front and center among all functions. The sales person who makes unrealistic promises to get the business  is as much responsible for safety as the dispatcher and train crew are. The safety "culture" needs to permeate all areas of the business and it needs to be the primary consideration when decisions are made. Most of us (well maybe not the railroads) are only one bad accident away from being obliterated.. one bad accident would put most of us out of business and would likely ruin our lives personally as well. Thus, safety first on all levels is the only way to go.. 

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Posted by tree68 on Wednesday, January 10, 2018 1:08 PM

As part of our "On Track" program, employees can file a good faith challenge.  That will be reviewed by management.  As I don't know of one actually being filed, I have no idea how one would turn out.  A verbal challenge can be "here and now," with a paper document filed later.

I'm in the process of setting up our annual "OSHA refresher" training for the fire department.  This year's program will emphasize workplace violence, hazmat, right-to-know, and blood-borne pathogens, among other topics.  

Firefighting can be very unpredictable.  Much is made of "situational awareness."  As the old saying goes, when you're up to your *** in alligators, it's hard to remember that your mission is to drain the swamp.

Firefighters have been lost because, from their point of view, the fight was worth fighting and kept pushing in.  Meanwhile, those with a better view of the situation knew it was time to step back.

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Posted by LithoniaOperator on Wednesday, January 10, 2018 1:50 PM

Could someone explain “three-step” to me?

If it’s effective, then what was the motivation of EHH (CSX prez?) to discontinue the practic?

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Posted by Overmod on Wednesday, January 10, 2018 2:08 PM

LithoniaOperator
Could someone explain “three-step” to me?

We had a thread on this specific topic a while back that described some of the different flavors of the rule: use the 'search community' box to the right and look for "A Little Blue Light."  Reading that would be better than a brief and incomplete recap now.

Meant to be an effective way to keep a train from moving when someone needs to 'get out and get under' where any part of the consist might hit or imperil them.  The analogue of blue flag protection for shopmen, or lockout/tagout for utilities. 

I'd be prepared to swear we had a comparatively recent thread on EHH that covered his objection to nominal three-step, whatever it was, but darned if I can find it with the search tool.

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Posted by Overmod on Wednesday, January 10, 2018 2:44 PM

selector
There is a great deal that is 'generalizable' over cultures and workplaces that can be called 'leadership'. The tone is set by those who seek, identify, and then hire the CEO, and that is probably a Board of Directors. After the seeking, identifying, and hiring come 'offering feedback', or what is often called 'quality control'. Where a CEO is held in high regard and left to her own devices, you get what you pay for. Where a Board is hands-on and vigilant, and offers meaningful feedback to the CEO, you get something else.

With respect, the most likely safety 'leadership' you should expect from a board or its chosen CEO is going to be peripheral, secondary to fiduciary responsibility to stockholders more likely than stakeholders.  Where you see 'safety' will be in response to perceived insurance costs and other monetizable liabilities.  This is not at all the level, or the mission, of typical corporate leadership.

A safety culture, like good quality management, requires first a 'constitutional' establishment of a need for formal procedures, and then 'championing' by the level of executive management tasked with a particular operating division or part of the organization.  There is a specific concern that isn't always observed, even in good organizations: there can be no reprisals for fair use of safety concerns, or refusal to follow instructions when based in reasonable safety policy.  Often hundreds of man-years of good design and safe operation can be undone with a few seconds of expedience - Challenger being one case in point, EHH's requiring in essence running when kicking cars being another.

It's easy to go overboard with rules-based safety backed up by hard consequences, usually taking already-hard-worked railroaders and giving it to them in the neck.  (That version of The Night Before Christmas with the "Three Wise Men" comes to mind...)  The Deepwater Horizon crew had an exhaustive safety culture ... which failed miserably when British corporate folks ordered a few poorly-chosen things.  Safe awareness, and working conditions that allow the right degree of vigilance to have good safe awareness, are probably as important as a plethora of defined rules and policies.  Reasonable review and refreshing is good; mandatory 'safety meetings' more for documentation than inspiration, and nit-picking or selective enforcement, not so good.

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Posted by selector on Wednesday, January 10, 2018 3:09 PM

Overmod

 

 
selector
There is a great deal that is 'generalizable' over cultures and workplaces that can be called 'leadership'. The tone is set by those who seek, identify, and then hire the CEO, and that is probably a Board of Directors. After the seeking, identifying, and hiring come 'offering feedback', or what is often called 'quality control'. Where a CEO is held in high regard and left to her own devices, you get what you pay for. Where a Board is hands-on and vigilant, and offers meaningful feedback to the CEO, you get something else.

 

With respect, the most likely safety 'leadership' you should expect from a board or its chosen CEO is going to be peripheral, secondary to fiduciary responsibility to stockholders more likely than stakeholders.  Where you see 'safety' will be in response to perceived insurance costs and other monetizable liabilities.  This is not at all the level, or the mission, of typical corporate leadership.

I think we agree here.  I meant that the buck stops at the very top, so if a culture goes bad, those at the top, a Board selecting a CEO, have only themselves to blame. We could call it a Type I error.  Most of them would start their remediation with either sanctioning the CEO or firing him outright.  I disagree that corporate leadership has little or nothing to do with a safety culture in their business any more than they'd think the same way about materiel supply, operational costs, capitalization, efficiencies, or anything else that could charitably be related to safety and its import.

Overmod

A safety culture, like good quality management, requires first a 'constitutional' establishment of a need for formal procedures, and then 'championing' by the level of executive management tasked with a particular operating division or part of the organization.  There is a specific concern that isn't always observed, even in good organizations: there can be no reprisals for fair use of safety concerns, or refusal to follow instructions when based in reasonable safety policy.  Often hundreds of man-years of good design and safe operation can be undone with a few seconds of expedience - Challenger being one case in point, EHH's requiring in essence running when kicking cars being another.

Yes, that is so.  Retribution, reprisals for good faith judgements, they have no place in a healthy organization unless the breach is indefensible.  As for 'constitutional', I think you mean that there ought to be published policies afforded to all workers for their learning and practice, after which there can be little argument as to whether or not the practices were adhered to, and where sanctions, usually stepped, can be adminstered (verbal warning, formal warning, counselling & probation, dismissal, as examples) in keeping with agreements such as a collective agreement.

Overmod

It's easy to go overboard with rules-based safety backed up by hard consequences, usually taking already-hard-worked railroaders and giving it to them in the neck...

But harder when life 'n limb are on the block.  Between one's conscience, one's insurer, and one's friends, a rise in those type of statistics won't be hard to understand, or to attempt to correct with determined and protracted steps.

Overmod

  (That version of The Night Before Christmas with the "Three Wise Men" comes to mind...)  The Deepwater Horizon crew had an exhaustive safety culture ... which failed miserably when British corporate folks ordered a few poorly-chosen things.  Safe awareness, and working conditions that allow the right degree of vigilance to have good safe awareness, are probably as important as a plethora of defined rules and policies...

Agreed, and that comes from leadership.  Hands-on leadership.  Vigilance, an instance on solid reporting, regular briefings, or any other way of showing that she cares.

Overmod

  Reasonable review and refreshing is good; mandatory 'safety meetings' more for documentation than inspiration, and nit-picking or selective enforcement, not so good.

 

IOW, poor leadership.

 
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Posted by tree68 on Wednesday, January 10, 2018 3:40 PM

LithoniaOperator
Could someone explain “three-step” to me?

Very briefly (Overmod's suggestion is a good one, though) - the three steps are setting the brakes, centering the reverser, and shutting off the generator field.  All of which serve to make the locomotive, anyhow, essentially unmovable.  There are other names for the practice, like "red zone."

The idea is to protect a crew member who has to go into the envelope of the train (say, to connect the brake hoses) from unwanted movement by temporarily disabling and securing (with air brakes) the locomotive...

LithoniaOperator
If it’s effective, then what was the motivation of EHH (CSX prez?) to discontinue the practice?

That's a very good question.  I don't know that anyone (other that EHH, etc) knows...

 

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Posted by SD70Dude on Wednesday, January 10, 2018 3:56 PM

Norm48327

Should that culture be implimented from the top down or the bottom up? Do track foremen have an obligation to their employees to enforce safety regulations? I believe so after watching my track foreman correct one of his employees.

Is being safety oriented directly related to the industry in which one is currently working or is it being able to read the big picture?

I know it's cliche, but a good safety culture requires buy-in from everyone, and the primary goal must actually be safety, not punishing those found to be unsafe.  I believe that (in the railroad environment at least) peer pressure is a far more effective incentive for safe practices than the fear of punishment by management, all that fear does is create a "us vs them" attitude which distracts from the true goal of safety.

But to establish enough peer pressure everyone needs to be on the same page, which means EVERYONE (management and employees) needs to have the same understanding of the rulebook.  Every manager having a different interpretation and little (if any) real-world experience does not cut it.  And that is the reality on many railroads today, including Amtrak.

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Posted by LithoniaOperator on Wednesday, January 10, 2018 5:07 PM

Thanks for the info re three-step.

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Posted by erikem on Wednesday, January 10, 2018 9:33 PM

I got a couple of examples of "safety culture" when doing subcontract work at an aerospace company.

First was "in case of fire, get out, don't be a hero, just get out."

Second was "Mistakes happen as part of being human. Where you get into serious trouble is lying about it."

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Posted by SD70Dude on Wednesday, January 10, 2018 9:39 PM

erikem

"Mistakes happen as part of being human. Where you get into serious trouble is lying about it."

The Class I Railroad version of that is:

"Mistakes are 100% the fault of the employee.  Employees will be in serious trouble if they are found to have made mistakes."

One can easily see how that discourages self-reporting and discussion, and encourages cover-ups.

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Posted by erikem on Wednesday, January 10, 2018 10:41 PM

I should caveat the "mistake" quote referring to mistakes that could cause the failure of a billion dollar rocket launch as opposed to running through a curve at excessive speed. The first can be corrected if the mistake is brought up in a timely manner, where the latter...

Incentivising covers ups is a bad idea either way.

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Posted by SD70Dude on Wednesday, January 10, 2018 10:52 PM

erikem

Incentivising covers ups is a bad idea either way.

Indeed, when near misses go unreported or are covered up the underlying problem remains, uncorrected.  That is until a major incident happens which is impossible to cover up.  

The Cascades 501 derailment appears to have been caused by unfamiliarity with the route, but the 188 (Frankfort Jct) derailment was not.  I wonder how many previous NEC trains had rounded that curve going too fast for one reason or another (Engineer fatigue, loss of situational awareness, etc).

I am sure they happened, and in a proper safety culture (without fear of massive reprisal) they would have been reported, and maybe something would have been done pre-emptively.  Like activating ACSES (PTC) in both directions, instead of just southbound.

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Posted by jeffhergert on Thursday, January 11, 2018 7:07 PM

tree68

 

It's been said, many, many times, that railroad rules are written in blood.  It's interesting that EHH's decree to stop using "three step" was met with a great deal of incredulity.  One can easily believe that even if the words aren't said over the air, that three step is still being used because the employees know it's the "safe route."

 

I can guarantee you that they (employees) protected themselves before "three-step" or "red zone" was put in place by management.  And I would expect even with the exact formality no longer codified in a rule, they still protect themselves.  They may be better off.  IMO, they seem to take good ideas and turn them into less about actual safety and more about the appearance (I suppose to the FRA and the public) of safety.  They become more about being able to hand out "gotcha" type discipline.  We have a couple of practices, that if you don't have your i's dotted and t's crossed just right, they'll be on you like flies on you know what.  Yet, if you follow them to the letter, dot the i's and cross the t's properly, there are loop holes that can still get the unwary hurt or killed.    

There is a safety culture program where I work.  Or maybe was, I don't hear much about it anymore.  It started in the mechanical department, was championed by a high level executive and rolled out to the rest of the railroad.  It wasn't supposed to be entirely management led but have input from the employees.  It did seem to work, for a while anyway.  (My BLE-T division didn't participate, while other divisions did.  [The BLE-T calls their locals, divisions.]   There were a couple of reasons.  One was more of a political us vs. them type reason.  I think they were wrong in that respect.  The other reason was that it was viewed as an entirely blame the worker program.  Along the lines of if someone was injured it was entirely their fault, that equipment might be defective is glossed over.)  The SMART-TD (formerly UTU) local did participate in my terminal.  At least until management (staff and territory) changes seemed to lessen management's buy in to the program.  At least that's the reason a former participant told me.  

------------------------------------------------------------------------------------------     

@jeff hergert,

 

Is tere any provision for filing such report or are you at the mercy of your employer?

Norm, there is a program to report near misses, etc anonymously.  It doesn't go to the railroad directly, but I think to the FRA.  There is/was a similar program that was also anonymous that went to the company/employee safety culture program I mentioned above.

------------------------------------------------------------------------------------------

The Class I Railroad version of that is:

 

"Mistakes are 100% the fault of the employee.  Employees will be in serious trouble if they are found to have made mistakes."

---

SD70Dude, don't you mean "when" not "if"?  

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Posted by tree68 on Thursday, January 11, 2018 7:29 PM

jeffhergert
I can guarantee you that they (employees) protected themselves before "three-step" or "red zone" was put in place by management. 

Wish I knew where I saw the video of a passenger engine change during the days of steam - the train hadn't stopped yet and a worker was between the tender and first car, working on making the break.

But that was in steam days.  

I agree that even without a codified rule today's workers will take the safe route - largely because it has become a way of doing business because it was codified.  When the engineer (or fireman) was almost always in view of the crew members, it was easy to protect, even without a formal procedure.  Nowadays a crew member may be well out of sight of (but in radio communication with) the engineer.

We often used hand signals to call for (and drop) three step.  The FRA wants it on the radio...

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Posted by SD70Dude on Friday, January 12, 2018 2:30 PM

jeffhergert

The Class I Railroad version of that is:

"Mistakes are 100% the fault of the employee.  Employees will be in serious trouble if they are found to have made mistakes."

---

SD70Dude, don't you mean "when" not "if"?  

Jeff

Why yes, yes I do.  Good catch, thanks.

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Posted by BaltACD on Monday, January 15, 2018 2:08 PM

For a 'true' Safety Culture to be established is has to be a top down undertaking.  Unless Senior Management buys in and enforces it on middle and first level management it is an excersize in 'gotcha'.  Having some first level supervisors disciplined for over emphasis on the 'gotcha factor' with the rank an file does wonders for employee morale.

         

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Posted by jeffhergert on Monday, January 15, 2018 2:45 PM

BaltACD

For a 'true' Safety Culture to be established is has to be a top down undertaking.  Unless Senior Management buys in and enforces it on middle and first level management it is an excersize in 'gotcha'.  Having some first level supervisors disciplined for over emphasis on the 'gotcha factor' with the rank an file does wonders for employee morale.

 

Last year one morning, at the Away From Home Terminal, the local low level manager left his door open during the morning conference call, which was on speaker phone.  (Being the lowest ranking terminal manager, the office was right next to the crew room.)  The division level management leading the conference call was doing just the opposite from what Balt said.  They were focusing on a specific rule (while they enforce all, they like to have blitzs on specific ones at times) praising the manager that had the most failures and belittling the one with the lowest failure rate.  Even telling those with lower failure rates they need to get more failures.  

Of course they didn't discuss why one manager had so many and the other had so few.  One would think the manager who couldn't find many failures had his people doing things the right way and would be commended for reaching that level.  That the one who had so many failures was the one having a problem not "managing" his people properly.  

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Posted by Deggesty on Monday, January 15, 2018 3:31 PM

Jeff, what a weasel the manager higher up is!

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  • From: Southeast Michigan
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Posted by Norm48327 on Monday, January 15, 2018 3:36 PM

Jeff,

I would not willingly work under such conditions. If I couldn't trust my boss to have a bit of compassion for those who unwittingly slipped up I would seek other employment. Having been involved in aviation maintenance for over thirty years and just waiting for the FAA to burn you I question why they are so quick to condemn rather than correct.

I suspect the FRA works about the same way as the FAA, and yes I have had moments in which I have had the FAA question my judgement on an issue. Thankfully I prevailed.

Norm


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