It sounds like a dark comedy scenario – “Hospital investigating operation on the wrong knee” (De Standaard, 10 Nov 2015) – but unfortunately, wrong-site surgery still exists, despite continuous efforts by the medical community. Rudy gives lectures in hospitals on the use of deceptively simple tools such as checklists, and how these fit into the bigger Just Culture picture. For years, he’s been equally dedicated to flying as he is to promoting safety across different industries.

Rudy, 38 years old, wears more than one hat: he is an A320 captain and Flight Safety Officer/Deputy Safety Manager at Thomas Cook Airlines, chair of BeCA’s Air Safety Committee and member of ECA’s Flight Data working group. He is one of ECA’s “Just Culture Ambassadors”.

Why do you find safety interesting?

“I have been involved in safety almost immediately after I started flying commercially, 10 years ago. But my proverbial fire was sparked by a presentation by Professor Sidney Dekker and a truly inspiring JAA SMS course in 2013.” He explains: “Maybe someday, I will be able to say: my efforts did help to prevent an accident. And maybe, they helped to prevent someone from getting killed or injured. That thought gets me going, every time I hit another wall in securing time or resources for a safety project.”

Just Culture, a shared responsibility

According to Rudy, these walls are often based on a lack of understanding. Just Culture is a shared responsibility between the pilots, who must report, and the management that has to ensure protection of the reporter. ICAO stipulates that one of the pre-requisites for an effective Safety Management System is top-level commitment. In other words: the accountable manager should be genuinely convinced of the importance of safety and lead by example.

Unfortunately, in reality, this is not always the case. “In most European airlines we face a ‘from-the-middle-out’ situation. The safety department and pilot representatives are safety devotees who wholeheartedly motivate their colleagues to report any issue, but the management must also commit to it.”

Compliance paradigm & common sense

“We seem to be stuck in the compliance paradigm. The first question most line managers ask me is: Is this really necessary? Or paraphrased: does our National Aviation Authority (NAA) consider this a requirement?” He illustrates how a Belgian company safety policy was printed on an A3 poster. “Because management wanted to make sure that everything was covered in case of an audit, the text had become utterly unreadable. The fact that the actual message to the staff was lost seemed of no importance.” For an efficient implementation of a reporting culture, some changes in this respect will be necessary.

Rudy cuts to the chase: “A safety policy should contain three items: 1. everybody is responsible for safety; 2. please report and 3. you will not be punished for honest mistakes. Clear, concise and to the point. In the end, safety must be practical and applicable, for everyone, whether it is flight crew, cabin crew, baggage loaders, check-in staff or the duty planner.”

Need for effective reporting

“You see, despite Flight Data Monitoring (FDM), ground reports and pro-active hazard hunting the majority of the safety threats remain below the radar. There are still too many things that go undetected. Situations that will pass unnoticed, unless reported. Yet these are the ones we really need to know about, in order to take action. These are the ones we need, in order to measure the complete iceberg; not just the mandatory tip.”

Report the unknown

Walking his own talk, Rudy usually probes for how less experienced crew perceive safety in their job. A short turn-around, to him, is an opportunity to go to the aft galley, where less experienced cabin crew members usually work – and a chance to ask them if they identified any hazards in the last weeks or months. Often, he gets a positive answer.

Rudy tells us how a purser told him about a new colleague lacking knowledge about basic emergency procedures. When he asked her why she did not report this issue earlier, the purser replied that she didn’t want to blame anyone. However when he asked if she would report, if she flew with the CCM again and the same problems surfaced, the answer was yes.

“Well, then the only reason for not reporting is your duty plan. If you don’t tell us, as a safety department, we simply don’t know what is going on.”

More flaps

Rudy doesn’t shy away from sharing a serious incident he was involved in. During initial line training, instead of extending the flaps, he retracted them. Luckily the indications on the speed scale immediately indicated the misconfiguration, flaps were extended again and the approach was continued to a safe landing.

“When driving home after that flight, I couldn’t stop thinking that my career was over.” However, the safety investigation concluded that he was never properly taught to check his action on the flap indication. “I moved the lever and I looked at it, instead of looking at the engine and warning display”. His mistake was identified as a no-blame error and Rudy kept on flying, thanks to the company’s Just Culture.

Feedback feedback feedback

“A few years later I found out about three several similar incidents which had happened before mine. I use this story in our SMS course. I did something wrong and I felt pretty bad about it. Actually, I still do. But as it turned out, I was not the only one making this mistake. Thanks to the investigation, internal training now emphasises the need to ‘do and check’. If our company would have known about these other occurrences, they probably would have adapted the training sooner and the incident might never have occurred.”

Getting people to report is one thing, making sure they continue to report is another. Here Rudy’s story underlines one of the most common points we’ve heard from pilots: that feedback, after reporting an incident, is often either partial, insufficient, late or completely missing.
“We’re going to hit a brick wall – again – if we don’t give feedback to people. No feedback is ‘a killer’ for reporting”. Rudy clearly sees a need for changing things on both sides when it comes to Occurrence Reporting – both airlines and crews have to make an extra effort. “It’s a shared responsibility.”

How do you see your role in safety?

“Merely gathering data is not enough. The analysis is the crucial step in bridging the gap between what is happening on the sharp end and translate it to management and vice versa.” Rudy continues: “If your board makes performance based decisions, they’d better be aware of the stories behind the numbers. Things look very different from behind an office desk than they do on a flight deck in turbulent night conditions”, he explains. “Procedures are set up by decision makers that don’t necessarily have adequate operational experience. That’s why it’s so tremendously important to keep in touch with the sharp end and realise the difference between work-as-done and work-as-imagined. A crucial part for me is to help the guys ‘upstairs’ to understand and appreciate what is going on in the real world. But also, to explain to the guys ‘downstairs’ the reasoning behind some top level decisions.”

People are safety

10 years down the road, Rudy shares his story of fortunate and less fortunate events, lucky coincidences and unexpected setbacks. With the hindsight benefit of how his personal choices have worked out, he speaks confidently about the topics he holds dear. That may explain the steadfastness he shows when we discuss his involvement in safety work. Once we focus on safety issues, he is on the ball, cites Dekker, Hollnagel and Woods passionately and uses the pillars of Safety Management Systems (SMS) to illustrate his own vision.

“If you want to improve safety, let’s start working together. We cannot be afraid to speak up, if we want to understand each other’s context. Speak out and talk with colleagues, industry stakeholders, airline management, the judiciary and even hospital staff. Take a look from inside their tunnel. Communication is key, because people are safety!”

Interview by ECA