1. Reprinted July 2012
Safety Culture
Definition and
Enhancement
Process

2. Safety Culture Definition Contents
and Enhancement Process
1_ Background_p3
2_ Safety Culture Definition and Elements_p3
2.1_ Proposed Safety Culture Definition_p3
2.2_ Safety Culture versus Safety Climate_p3
2.3_ Proposed Safety Culture Elements_p4
3_ Systematic Safety Culture Enhancement Process_p6
3.1_ Define the Safety Culture_p7
3.2_Identify Drivers of a Safety Culture_p8
3.3_Measuring the Safety Culture_p9
3.4_Evaluating the Measures_p10
3.5_Improving the Safety Culture_p10
3_ Conclusions_p11
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may be reproduced, or transmitted in any form, without the prior
permission of CANSO.
This document has been developed through the collective contributions
of CANSO members. The views and recommendations expressed in this
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We have endeavoured to ensure the integrity of this publication insofar
as possible. However, please note that the responsibility for the quality,
accuracy, and verification of the data and results in this report rests with
participating ANSPs. All recommendations are made without any warranty
or guarantee on the part of the contributors or CANSO. CANSO disclaims
any liability in connection with the use of this publication or any aspect
thereof.

3. Safety Culture Definition 2_3
and Enhancement Process
1
Background
The detailed work plan for Year One for address the fact that a safety culture is
the CANSO Safety Culture Workgroup (CSCWG) demonstrated through attitudes, accepted norms
identified a number of activities. Two key and behaviours. It is about how things work and
deliverables for the year are: “the way things are done around here.”
Finally, the safety culture definition should
1. CANSO Safety Culture Definition be related directly to the safe provision of air
2. Safety Culture Enhancement Process navigation. On the other hand, it should not include
Model worker safety which comes under the purview
of occupational health and safety, which is not
This document was prepared by the CANSO in the scope of the CSCWG. However, it can be
Safety Culture Workgroup. It presents a proposal assumed, that a good safety culture focused on
for the above deliverables for review, comment service provision also has a positive effect on
and acceptance by the CANSO Safety Standing occupational health and safety.
Committee (SSC). Based on the review, further discussion and
the elements presented above, a safety culture
2 definition for use by CANSO was developed. The
Safety Culture Definition and Elements proposed definition is:
“Safety culture refers to the enduring value,
2.1_Proposed Safety Culture Definition
priority and commitment placed on safety by every
A review of a number of definitions of safety
individual and every group at every level of the
culture was conducted by the CSCWG. This review
organisation. Safety culture reflects the individual,
included identifying the strengths and weaknesses
group and organisational attitudes, norms and
of each definition.
behaviours related to the safe provision of air
The review identified a number of elements
navigation services.”
necessary for a good safety culture definition.
First and foremost the definition should recognise
2.2_Safety Culture versus Safety Climate
that a safety culture reflects individual, group and
One of the issues highlighted in the literature
organisational attitudes, norms and behaviours.
is the lack of universal consensus regarding the
Safety culture is not just a reflection of the individuals
terms safety culture and safety climate. Much
that make up an organisation; an organisation’s
debate still continues over the definition and
safety culture is more than the sum of its parts.
application of the terms and they are often used
Secondly, a safety culture definition must
interchangeably. For the purpose of CANSO and
recognise that safety culture is reflected in the
its related safety culture work, there will be a
value of, priority of and commitment to safety. An
distinction between the two terms.
organisation with a strong safety culture values
Safety Culture has been defined above
the importance of safety; it recognises that safety
and is seen as representing the more enduring,
is a business imperative. Safety is also afforded
underlying culture surrounding safety in an
the highest priority over commercial, operating,
organisation whereas safety climate represents
environmental and social pressures. And finally,
what people feel and their perceptions about
there is a commitment to safety; safety issues
safety at a given point in time. There safety
receive the attention warranted by their significance.
climate measurement provides a snap-shot of
A safety culture definition should also

4. Reprinted July 2012
the state of an organisation’s safety. Typically 2.3_Proposed Safety Culture Elements
the safety climate is measured using quantitative As well as a definition, the CSCWG is
questionnaires while assessing safety culture proposing that safety culture may be further
requires more qualitative methods. defined by eight key elements: Informed Culture,
As presented by Cox and Cox (1996), safety Reporting Culture, Just Culture, Learning Culture,
culture can be likened to personality, whereas Flexible Culture, Risk Perception, Attitudes to
climate is likened to mood. Both can change within Safety and Safety-Related Behaviour. These
an organisation. However, like one’s personality, elements were chosen as they reflect work by
safety culture takes time to grow and change; you James Reason and add three elements that were
can not “implement” a safety culture but it can be identified previously by the CANSO safety culture
re-directed through concerted effort and action working group (see Figure 1). Table 1 (see page
by an organisation. Safety climate, as with one’s 5) presents the definition and an explanation of
mood, can change more quickly and dramatically each element. It is important to note that there
given the circumstances and current conditions are interrelationships between the elements. For
being faced by an organisation and the resulting example, an informed culture must relay on a good
actions taken. You try to shape the culture over reporting culture, which it turn depends upon a
time by changing the climate. just culture. Not only must the interrelationship
between the elements be considered but the role of
management in establishing the policies, procedures
and tools to foster those elements and committing
to their success. With these, an organisation can
achieve a strong, positive safety culture.
Figure 1 Elements of a Safety Culture
Safety Risk
Related Perception
Behavior
Attitudes
to Safety

5. Safety Culture Definition 4_5
and Enhancement Process
Element Description Explanation
Just Culture An atmosphere of trust in which An informed culture relies on a reporting culture which in turn
people are encouraged for relies on a Just Culture. All employees must clearly understand
providing essential safety-related and recognise that it is unacceptable to punish all errors and
information, but in which they unsafe acts regardless of their origins and circumstances
are also clear about where the while it is equally unacceptable to give blanket immunity
line must be drawn between from sanctions to all actions that could, or did, contribute
acceptable and unacceptable to organisational accidents. A prerequisite for engineering a
behaviour. just culture is an agreed set of principles for drawing the line
between acceptable and unacceptable actions.
Reporting Managers and operational The issue is not whether the organisation has a reporting
Culture personnel freely share critical system; it is whether, as a matter of practice, errors, near
safety information without the misses, hazards and risks are reported. A reporting culture
threat of punitive action. depends, in turn, on how the organisation handles blame and
punishment. If blame is the routine response to error, then
reports will not be forthcoming. If, on the other hand, blame is
reserved for truly egregious behaviour, involving recklessness
or malice, reporting in general will not be discouraged. Rather
than a blanket no-blame approach, what is required, Reason
argues, is a just culture.
Informed Those who manage and operate Management fosters a culture where people understand
Culture the system have current the hazards and risks inherent in their areas of operation.
knowledge about the human, Personnel are provided with the necessary knowledge, skills
technical, organisational and and job experience to work safely, and they are encouraged
environmental factors that to identify the threats to safety and to seek the changes
determine the safety of the necessary to overcome them. An informed culture relies on
system as a whole. having a strong reporting culture.
Learning An organisation must possess the Reports are only effective if an organisation learns from them.
Culture willingness and the competence Learning will occur from both reactive and proactive safety
to draw the right conclusions assessments and is promoted by an inherent organisational
from its safety information system willingness to adapt and improve.
and the will to implement major
reforms.
Flexible A culture in which an organisation A culture of safety is flexible, in the sense that decision-
Culture is able to reconfigure themselves making processes vary, depending on the urgency of the
in the face of high tempo decision and the expertise of the people involved.
operations or certain kinds of
danger – often shifting from the
conventional hierarchical mode to
a flatter mode.
Risk Individuals at all organisational It has been found that misperceptions of the seriousness of
Perception levels need to have the same risks occur frequently at all levels in an organisation (HSC,
perceptions and judgments of 1993). The perception of risk or people’s judgments of
the seriousness of risks, as these riskiness is influenced by different attributes of hazards, e.g.
perceptions affect risk behaviour controllable-uncontrollable. Misjudgements of risks may
and appropriate decisions with cause risk behaviour and inappropriate decisions with regard
regard to safety issues. to safety measures and ordinary occupational accidents as
well as large-scale accidents (Rundmo, T., 1997. Associations
between risk perception and safety. Safety Science 24 (3),
197-209).
Attitudes to Attitudes (especially Research has shown that attitudes to safety can be associated
Safety management’s) in relation to with risk perception and safety-related behaviours.
safety, risk and production.
Safety- Safety-related behaviour has Having accurate risk perceptions does not necessarily result
related to do with directly complying in correct risk and safety related behaviours. Ignorance or
behaviour with procedures, rules and deliberate violations to safety rules and procedures are often
regulations, but also to aspects due to employee attitudes towards risk and safety (HSC,
such as coaching, recognising, 1993). Hale (2003) advances the shared purpose in safety
communicating, demonstrating, performance, i.e. the involvement felt by all parties in the
and actively caring. organisation, especially the workforce, in the process of
defining, prioritising and controlling risk.

6. Reprinted July 2012
3
Systematic Safety Culture Enhancement Process
Once it has been decided to enhance an What was going to be measured was defined in
organisation’s safety culture, a systematic, closed- the first step; next, how, who, and when must be
loop process for doing so must be selected. determined.
A typical enhancement process is presented Once the measurement activities have
in Figure 2. First and foremost, what is meant been completed, the results must be evaluated.
by safety culture in your organisation must be Interpreting the results can be challenging and the
understood. How will safety culture be defined? results need to have credibility both internally and
What will be the sub-components? What will be externally.
the characteristics? Before something can be After the evaluation has been completed
measured, you must first define and describe what and interpreted, an action plan needs to be
it is that you want to measure. developed to address any identified weaknesses.
The next step involves identifying the drivers The enhancement process then repeats itself in
of safety culture. If you know who or what drives due time, in order to check the new level of safety
culture then you are in a better position to know culture reached and to confirm if the actions taken
who or what you can elicit to help change or have been effective providing measures over time.
maintain it. It is important to note that safety culture measures
The third step involves measuring the safety are but one metric that can be used to evaluate
culture. Tools and process must be selected the “safety state” of an organisation and in order
that best meet the organisation’s requirements. to obtain a full picture other safety performance
measures should be established.
Figure 2 Systematic Safety Culture Enhancement Process
{
{
{ }

7. Safety Culture Definition 6_7
and Enhancement Process
3.1_Define the Safety Culture
In order to determine what you are going to aspect here is management’s commitment to
assess and to select the appropriate measurement safety – Is there an understanding and acceptance
tools, it is first necessary to determine what of the current safety state? Is safety afforded
approach you will use to model your safety the right priority? Are the appropriate resources
culture. A useful framework based on the work assigned to safety?
by M.D. Cooper is to distinguish between three The situational aspects of safety culture
interrelated aspects of safety culture (see Figure 3). describe ‘what the organisation has’. This is
The psychological aspects of safety reflected in the organisation’s policies, operating
culture refers to ‘how people feel’ about procedures, management systems, control
safety and safety management systems. This systems, communication flows and workflow
encompasses the individual and group values, systems. These aspects can also be described as
attitudes and perceptions regarding safety, which “organisational factors”.
is often referred to as the safety climate of the The connecting arrows between the boxes
organisation. reflect the view that the three aspects of safety
culture are interrelated and are therefore not
Behavioural aspects are concerned with mutually exclusive. It is important to note that
‘what people do’ within the organisation, which when looking at the different aspects one must
includes the safety-related activities, actions and not only look at the “what or how” but also the
behaviours exhibited by employees. A critical “why”. Without understanding why people
Figure 3 Safety Culture Framework

8. Reprinted July 2012
feel they way they do or why they do what they do 3.2_Identify Drivers of a Safety Culture
or why the organisation has what it does, changes Cultural drivers focus on two main areas
implemented to improve culture may not address – organisational and those which relate to ‘key
the underlying issues and therefore will likely be individuals’. Organisational drivers may be
inappropriate and/or ineffective. characterised by management systems and
A model such as the illustrated in Figure 3 procedures in a variety of areas of organisational
will prove useful when the time comes to select activity. These drivers include both internal
the safety culture assessment tool you will use. and external influences. Examples include:
One can find in literature many suggestions corporate business plan, corporate safety
as to how best to define safety culture along with plan, organisational systems, procedures and
the key characteristics or indicators as illustrated standards. External examples include: regulatory
in Figure 4. Reason breaks safety culture down and legal requirements as well as industry
into five elements – Reporting, Just, Flexible, standards.
Learning and Informed. Ron Westrum and Mark Key groups and individuals within an
Flemming have identified lower level indicators organisation can influence and drive culture
which can be, in some instances, mapped directly both directly and indirectly through their actions,
into Reason’s elements. It is necessary to select words and commitment. There can be a strong
and define the indicators that will be used to relationship and influence between group
measure safety culture before selecting the behaviours and individual drivers. Groups within
methods and tools that will be employed. an organisation can be professional groups,
Figure 4 Indicators of a Safety Culture

9. Safety Culture Definition 8_9
and Enhancement Process
labour groups. Just some of the many possible define safety culture and its key indicators.
individual drivers include the CEO, Senior These tools and frameworks allow
management, safety personnel, “champions” and organisations to determine the extent to which
of course the employees themselves. the indicators of a strong safety culture exist in
Knowing the key drivers will be important an organisation and/or have been instilled in the
when it comes to evaluating any measurement behaviours of managers and employees.
results and planning safety culture enhancement The selection of the tool or tools that will be
strategies. An organisation can use these drivers to used depends upon a number of factors, including
develop and implement strategies for improving its what will be measured, resources and schedule.
safety culture. Going back to our model of a safety culture (See
Figure 5), you can see that different tools are used
3.3_Measuring the Safety Culture depending upon which aspects of a safety culture
There are many tools that have been you want to assess. For example, questionnaires
developed to measure the various aspects of can be used to assess the psychological or
safety culture. Some focus only on operational behavioural aspects. It is important to realise,
safety (keeping the public safe from accidents and when using them to assess what people do, they
incidents), others looks primarily at Occupational will collect data about what people believe or
Health and Safety (keeping workers safe), while perceive that they do and not what they actually
others look at both. This is why it is so important do. On the other hand, audits and observations
for an organisation to determine how it wants to are tools that when applied properly will more
Figure 5 Possible Measurement Tools

10. Reprinted July 2012
accurately reflect what is happening in the 3.4_Evaluating the Measures
workplace as well as what the organisation has. Interpreting the results produced by the
When determining which tools to use, there are a various safety culture measurement tools can
number of factors that must be considered. be daunting. Each tool can have its own unique
First and foremost, you must determine challenges.
what it is that you are planning on measuring. It For surveys, did the respondents
is important for those planning to measure safety understand the question? Why did they answer
culture to take into consideration the level of the way they did? For interviews, were the
trust of employees towards those managing the participants open and honest? If they do not trust
assessment. For example if interviews or focus the process or those conducting the interviews,
groups are held and there is a low level of trust, the data collected may be incomplete and
then the results may be biased. Or for a survey, if inaccurate. For audits, are you actually capturing
employees do not believe that confidentiality will the day-to-day activities or are those being
be maintained, then the response rate may be low. audited on their best behaviour? Or perhaps they
With regards to the utility of results you spent the week prior to the audit, catching up on
need to consider the amount of data that will be things.
produced, how difficult it will be to analyse the By using different measurement tools, you
data and, in turn, to interpret the results. Will the can address weaknesses in one by the strengths
tool allow comparability between assessments in another. For example, you can follow-up a
as well as across groups? Will a link be seen safety culture survey with focus groups in order
between the data collection efforts and the to explore respondents’ understanding of key
identified actions? For example, Interviews questions and to obtain a better and deeper
can limit comparability particularly between understanding of the findings.
assessments. Surveys can offer comparability There are many different ways to measure,
between assessments as well as groups. and in turn present, the results of a safety culture
Cost is important and is affected by a assessment. It is important to understand what it
number of factors. Is there an inexpensive tool is you are measuring and what are the best means
available that you can purchase, can one be easily for presenting the results. Examples include
modified or do you have to undertake expensive frequency charts, radar plots and comparison’s
development? How much time will be spent in against normed databases.
applying the tool and analysing the results?
What are the logistical costs – 3.5_Improving the Safety Culture
communications, survey administration and travel The final step of the safety culture
are just some that need to be considered. enhancement process is “closing the safety loop”.
Lastly but just as importantly you need to It is important that assessments of safety culture
consider what is the timeframe for completion of be followed by change where weaknesses have
the activity and how quickly does the assessment been identified. Employees will disengage from
need to be completed? the enhancement process if they see no real
benefits from participating.
By using the appropriate tools and
accurately evaluating the results, you will be able

11. Safety Culture Definition 10_11
and Enhancement Process
4
Conclusion
to develop enhancement strategies and formulate The achievement of an effective safety
action plans. Enhancement strategies will focus on culture is recognised to be a vital element of
weaknesses identified by your safety indicators. achieving and maintaining satisfactory levels of
Do you have weaknesses in the area of trust, safety performance. A Systematic Safety Culture
communications, learning or perhaps perceptions Enhancement Process is a managerial tool
on consistency between words and actions? allowing organisations to identify areas where
Action plans must be realistic and safety culture may be enhanced. The process of
employees must be able to see the links between enhancement begins with a model of an effective
the action plans and the identified weaknesses safety culture – in other words a safety culture
in safety culture. Don’t forget to consider your definition and its elements as presented previously
organisation’s vision or mission. Make sure that in Section 2.
the actions tie into the business plan if you hope The enhancement process moves onto
to have senior management support and the measuring and evaluating the safety culture.
necessary resources to undertake the planned There are many available tools for measuring and
actions. Here is where you look back to those evaluating safety culture. The selection of the
safety culture drivers. Look to see how you can appropriate measurement tools begins with the
best use them to drive your action plans. model and takes many factors into effect including
Finally remember that timely feed-back and but not limited to cost, time, confidentiality
follow-up is critical - do this as soon as possible requirements, ease of data analysis and usefulness
after completion of the assessment so that staff of output for planning of enhancement actions. The
sees that momentum is being maintained. If your CSCWG will begin to look at developing such tools
are providing feedback following the introduction in future years.
of enhancement actions or other changes, make It is important to recognise that the
clear how the changes relate to the findings of the Systematic Safety Culture Enhancement Process
safety culture assessment, what the changes are is a closed loop system. Following implementation
and what employees can expect to see. Do this at of enhancement actions, an organisation must
the beginning of the feedback process. begin again by measuring the safety culture to
determine the impact of those actions. Did they
have the intended effect? Are there areas that
require further enhancement or fine tuning? As
Mao Tse Tung once said, “Peoples attitudes and
opinions have been formed over the decades of life
and cannot be changed by having a few meetings
or giving a few lectures”.
And finally, a last thought from James
Reason:
If you are convinced that your organisation
has a good safety culture, you are almost certainly
mistaken ... a safety culture is something that is
striven for but rarely attained. The virtue – and
the reward – lies in the struggle rather than the
outcome.

12. CANSO Members
CANSO – The Civil Air Navigation Services
Organisation – is the global voice of the companies
that provide air traffic control, and represents
the interests of Air Navigation Services Providers
worldwide.
CANSO members are responsible for supporting
over 85% of world air traffic, and through our
Workgroups, members share information and
develop new policies, with the ultimate aim
of improving air navigation services on the
ground and in the air. CANSO also represents its
members’ views in major regulatory and industry
forums, including at ICAO, where we have official
Observer status. For more information on joining
CANSO, visit www.canso.org/joiningcanso.
Lighter areas represent airspace covered by CANSO Members
Full Members - 74
— Aeronautical Radio of Thailand (AEROTHAI) — Maldives Airports Company Limited (MACL) — ATCA – Japan
— Aeroportos de Moçambique — Malta Air Traffic Services (MATS) — ATECH Negócios em Tecnologia S/A
— Air Navigation and Weather Services, — NATA Albania — Aviation Advocacy Sarl
CAA (ANWS) — National Airports Corporation Ltd. — Avibit Data Processing GmbH
— Air Navigation Services of the Czech Republic — National Air Navigation Services Company — Avitech AG
— AZIMUT JSC
(ANS Czech Republic) (NANSC)
— Barco Orthogon GmbH
— Air Traffic & Navigation Services (ATNS) — NATS UK — Booz Allen Hamilton, Inc.
— Airports and Aviation Services Limited (AASL) — NAV CANADA — Brüel & Kjaer EMS
— Airports Authority of India (AAI) — NAV Portugal — Comsoft GmbH
— Airservices Australia — Naviair — Abu Dhabi Department of Transport
— Airways New Zealand — Nigerian Airspace Management Agency (NAMA) — Dubai Airports
— Angkasa Pura I — Office de l’Aviation Civile et des Aeroports — EADS Cassidian
— Austro Control (OACA) — EIZO Technologies GmbH
— Avinor AS — ORO NAVIGACIJA, Lithuania — European Satellite Services Provider (ESSP
— AZANS Azerbaijan — PNG Air Services Limited (PNGASL) SAS)
— Emirates
— Belgocontrol — Polish Air Navigation Services Agency (PANSA)
— Entry Point North
— Bulgarian Air Traffic Services Authority — Prishtina International Airport JSC
— Era Corporation
(BULATSA) — PT Angkasa Pura II (Persero) — Etihad Airways
— CAA Uganda — ROMATSA — Fokker Services B.V.
— Civil Aviation Authority of Bangladesh (CAAB) — Sakaeronavigatsia Ltd — GE Aviation’s PBN Services
— Civil Aviation Authority of Singapore (CAAS) — S.E. MoldATSA — Guntermann & Drunck GmbH
— Civil Aviation Regulatory Commission (CARC) — SENEAM — Harris Corporation
— Department of Airspace Control (DECEA) — Serbia and Montenegro Air Traffic Services — Helios
— Department of Civil Aviation, Republic of Agency (SMATSA) — HITT Traffic
Cyprus — Serco — Honeywell International Inc. / Aerospace
— IDS – Ingegneria Dei Sistemi S.p.A.
— DFS Deutsche Flugsicherung GmbH (DFS) — skyguide
— Indra Navia AS
— Dirección General de Control de Tránsito — Slovenia Control
— Indra Sistemas
Aéreo (DGCTA) — State Airports Authority & ANSP (DHMI) — INECO
— DSNA France — State ATM Corporation — Inmarsat Global Limited
— Dutch Caribbean Air Navigation Service — Tanzania Civil Aviation Authority — Integra A/S
Provider (DC-ANSP) — The LFV Group — Intelcan Technosystems Inc.
— ENANA-EP ANGOLA — Ukrainian Air Traffic Service Enterprise — International Aeronavigation Systems (IANS)
— ENAV S.p.A: Società Nazionale per l’Assistenza al (UkSATSE) — Iridium Communications Inc.
Volo — U.S. DoD Policy Board on Federal Aviation — Jeppesen
— Entidad Pública Aeropuertos Españoles y — LAIC Aktiengesellschaft
— LEMZ R&P Corporation
Navegación Aérea (Aena) Gold Associate Members - 13 — LFV Aviation Consulting AB
— Estonian Air Navigation Services (EANS) — Abu Dhabi Airports Company — Micro Nav Ltd
— Federal Aviation Administration (FAA) — Airbus ProSky — The MITRE Corporation – CAASD
— Finavia Corporation — Boeing — MovingDot
— GCAA United Arab Emirates — BT Plc — New Mexico State University Physical Science Lab
— General Authority of Civil Aviation (GACA) — FREQUENTIS AG — NLR
— Hellenic Civil Aviation Authority (HCAA) — GroupEAD Europe S.L. — Northrop Grumman
— HungaroControl Pte. Ltd. Co. — ITT Exelis — NTT Data Corporation
— Israel Airports Authority (IAA) — Project Boost
— Lockheed Martin
— Irish Aviation Authority (IAA) — Quintiq
— Metron Aviation
— ISAVIA Ltd — Rockwell Collins, Inc.
— Raytheon — Rohde & Schwarz GmbH & Co. KG
— Kazaeronavigatsia — SELEX Sistemi Integrati S.p.A. — Saab AB
— Kenya Civil Aviation Authority (KCAA) — Telephonics Corporation, ESD — Saab Sensis Corporation
— Latvijas Gaisa Satiksme (LGS) — Thales — Saudi Arabian Airlines
— Letové prevádzkové Služby Slovenskej — SENASA
Republiky, Štátny Podnik Silver Associate Members - 61 — SITA
— Luchtverkeersleiding Nederland (LVNL) — Adacel Inc. — STR-SpeechTech Ltd.
— Luxembourg ANA — ARINC — Tetra Tech AMT
— Washington Consulting Group
— WIDE
Correct as of 5 July 2012. For the most up-to-date list and organisation profiles go to www.canso.org/cansomembers