Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes (2022)

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33 In late 2019, in the aftermath of the 737 Max 8 crashes, the Federal Avia- tion Administration (FAA) conducted a safety culture survey of the roughly 7,000 member staff in its Aviation Safety (AVS) office. This report was not made public, but excerpts were leaked to the press in 2020 (Duncan and Aratani, 2020; Shepardson, 2020). The committee has not seen the 2019 survey and cites press accounts in this chapter to explain the events that led to a congressional mandate for a regular schedule of surveys and assess- ment of AVS’s safety culture. Approximately one-quarter of AVS employees responded to the survey. Survey responses included concerns by some employees about being under undue pressure from industry to approve their products and activities, as well as fears that FAA senior managers were “overly concerned” about helping corporations rather than being exclu- sively focused on safety. (See also Box 3-1 for other concerns raised by some employees.) Some of the respondents did not feel that FAA was living by the safety values it espouses. For example, one respondent, a Seattle-based FAA safety engineer excluded from the 737 Max 8 certification process, who was a key whistle blower on the Max 8 incident, described FAA “as an organization with a militaristic chain of command, in which lower-level employees can offer opinions when asked but otherwise must ‘sit down and shut up’” (Gates, 2021). Troubled by the implications of the media cover- age of the survey and employee concerns about the certification process, Congress subsequently required FAA to conduct an annual safety culture survey of AVS. The committee’s Statement of Task directs it to “draw on the results of FAA’s annual internal safety culture assessments and advise the agency 3 Safety Culture and Its Assessment

34 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 BOX 3-1 Excerpts from Shepardson (2020), Reuters The safety culture survey, conducted in late 2019 and in focus groups in early 2020, said employees and managers reported “external pressure from industry is strong and is impacting” the safety culture. “They shared that there is an un- written code to be more ‘liberal-minded’ (versus conservative) when assessing safety risks, and there is pressure to find win-win solutions that benefit industry,” the survey found. “Many reported that industry will escalate issues to senior leadership and/or Congress if FAA employees are perceived as ‘getting in their way,’ which directly leads to decisions that are friendlier to industry (i.e., to help meet timelines and manage costs of industry applicants and operators),” the survey added. Nearly half of survey respondents disagreed that the FAA makes data-driven decisions on safety regardless of external pressure. Agency employees said they can be “over-powered in meetings with industry,” with one unnamed employee saying: “It feels like we are showing up to a knife fight with Nerf weapons. It is a challenge to be an equal match with Boeing in the meetings/ conversations.” on data and approaches for assessing safety culture to ensure that FAA is identifying emerging risks to commercial aviation and sharing that infor- mation throughout FAA and with the public.” This chapter introduces the specific task of reviewing and drawing on AVS’s safety culture assessment and also broadens the discussion of safety culture in ways that apply more generally to how assessments of safety culture across commercial aviation can provide precursor information to guide safety management. We begin with a definition of safety culture in the next section. We then review what the committee has learned from AVS’s efforts to date. After next sum- marizing best practice in safety culture assessment, the final section offers conclusions pertinent to FAA as a regulator and to the aviation industry more broadly. Throughout this chapter, the committee quotes extensively from the 2016 National Academies report Strengthening the Safety Culture of the Offshore Oil and Gas Industry because of its cogent description of the safety culture assessment process. SAFETY CULTURE Organizational culture, based on Schein (2004), “is typically thought to consist of artifacts (e.g., surface aspects that are easy to discern, such as dress), espoused beliefs and values, and basic and underlying assumptions (i.e., unconscious, taken-for-granted beliefs and values).” “The subset of assumptions about safety in an organization can be loosely labeled safety

SAFETY CULTURE AND ITS ASSESSMENT 35 TABLE 3-1 Traits of a Positive Safety Culture Traits Behaviors Leadership Safety Values and Actions Leaders demonstrate a commitment to safety in their decisions and behaviors. Problem Identification and Resolution Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. Personal Accountability All individuals take personal responsibility for safety. Work Processes The process of planning and controlling work activities is implemented so that safety is maintained. Continuous Learning Opportunities to learn about ways to ensure safety are sought out and implemented. Environment for Raising Concerns A safety conscious work environment is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. Effective Safety Communications Communications maintain a focus on safety. Respectful Work Environment Trust and respect permeate the organization. Questioning Attitude Individuals avoid complacency and continually challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. SOURCE: NRC, n.d. culture, encompassing the organization’s values, attitudes, beliefs, social norms, rules, competencies, and behaviors regarding safety” (Schein, 2010). Safety culture can be thought of as reflecting the priority that an organi- zation places on safety relative to other organizational goals (Zohar and Hofmann, 2012). Notably, the unconscious, taken-for-granted beliefs and values of an organization’s culture can be difficult for its own members to articulate and, as discussed in a subsequent section, not reliably assessed by surveys alone. Corporate culture, a somewhat nebulous concept that can be hard to grasp, defines the unwritten rules of behavior for the organization from hiring practices to how people make decisions. The Nuclear Regulatory Commission (NRC), an organization with a recognized safety culture, de- fines safety culture as core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over compet- ing goals to ensure protection of people and the environment (NRC, n.d.) with traits summarized in Table 3-1. The National Academies’ 2016 safety

36 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 culture report quoted extensively herein is recommended as a reference for the research that validates and elaborates on these traits (NASEM, 2016).1 The traits listed in the table are interrelated. For example, leadership has to create the conditions and communicate the values that result in high levels of trust and respect and an environment for raising concerns such that front-line workers feel free to report errors or issues without fear of recrimination and with an assurance that management will evaluate and act on them as appropriate. Another trait of a strong safety culture is the establishment of measurable safety goals, the continuous tracking of performance against those goals, and continuous safety improvement. Particularly pertinent to this report are the traits of “problem identification and resolution,” “environment for raising concerns,” and “questioning attitude.” These are important means to monitor and address gaps in an organization’s ability to identify and manage potential hazards. AVS SAFETY CULTURE ASSESSMENT TO DATE In the aftermath of FAA’s leaked safety culture survey, FAA put in place a voluntary, non-punitive reporting system for AVS employees. At the time of the AVS briefing to the committee (January 2022), the system had roughly 400 reports, but analysis of the results was not available at the time, nor were summaries of the raw data. As noted in Chapter 2, reports by front-line workers of incidents and near misses provide much of the precursor information that organizations depend on to manage safety. As discussed further in Chapter 4, overcoming hesitancy on the part of front-line individuals to submit reports to the vol- untary reporting systems is greatly helped by laws and regulations making such reports confidential and non-punitive. In particular, if an airline or air traffic control employee violates a procedure or policy, which can be subject to discipline, the information divulged cannot be used for enforcement if it is reported in a voluntary reporting system, as long as the behavior does not reflect criminal or intentional wrongdoing. The system put in place by AVS is confidential and non-punitive for AVS employees, insofar as reporters cannot be punished for pointing out their own lapses or for their criticism of AVS management policies they feel may be compromising FAA’s com- mitment to safety. The roughly 400 voluntary reports that had been submitted to AVS as of January 2022, and those collected since then, may provide valuable insights. If each report is by a unique individual employee, it would indicate 1 See Chapter 2: Safety Culture. Note that this chapter refers to the safety culture principles espoused by the Department of the Interior, which, in turn, are largely based on the NRC’s list of traits.

SAFETY CULTURE AND ITS ASSESSMENT 37 that 6% of the AVS 7,000-member workforce has raised safety issues with FAA management. The committee looks forward to learning about these reports in subsequent briefings from AVS. FAA AVS officials stressed that their efforts to improve the AVS safety culture had been under way for quite some time. They cited their effort as striving to achieve key elements of safety culture espoused by Reason (1997), which they described as follows: • Just culture—Employees feel free to speak up about safety concerns without retribution and comfortable that information will be used appropriately. • Reporting culture—Errors are seen as non-punitive opportunities to learn based on a free flow of information. Reporting is actively encouraged and confidentiality is ensured. • Learning culture—The organization learns from mistakes based on collected information and does so in an environment in which errors are accepted and employees are not blamed for them. • Flexible culture—The organization is adaptive to changing demands and understands how to manage safety and encourages open discus- sion about differences of opinion. • Informed culture—The organization collects, shares, analyzes, and acts on information. Reason’s model for generating precursor information is clearly what the AVS officials stressed, but the elements of Reason’s work that was cited did not include how safety culture itself is developed within organizations. The safety culture attributes listed by AVS officials and the traits encouraged by the NRC overlap. The differences lie in their emphasis. AVS placed less emphasis on NRC’s safety culture traits of leadership, communication, and work processes. However, achieving a stronger safety culture within AVS will depend on leadership follow-up, communication, and development and implementation, or revision, of appropriate work practices for certification and inspection. In addition, Reason recognizes the problem of successful organizations becoming complacent in the context of rare, infrequent acci- dents: in the spirit of the safety culture trait of maintaining a “questioning attitude” he describes the danger of organizations that “forget to be afraid” (Reason, 2002). Such an inquiring attitude is a hallmark of high-reliability organizations (La Porte and Consolini, 1991; Roberts, 1990; Weick et al., 1999), which manifest a positive safety culture with a state of constant “mindfulness” about hazards and risk that is emphasized and modeled by leadership (Weick and Sutcliffe, 2015). Organizational mindfulness as developed by Weick and Sutcliffe (2015) is summarized in Box 3-2. The benefits of these practices have been reflected

38 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 BOX 3-2 Five Practices for Developing “Mindfulness” 1. Preoccupation with failure. Encourage the reporting of errors and pay attention to any failures. These lapses may signal possible weakness in other parts of the organization. Too often, success narrows perceptions, breeds overconfidence in current practices, and squelches opposing viewpoints. This leads to complacency that in turn increases the likelihood unexpected events will go undetected and snowball into bigger problems. 2. Reluctance to simplify interpretations. Analyze each occurrence through fresh eyes and take nothing for granted. Take a more complex view of matters and look for disconfirming evidence that foreshadows unexpected problems. Seek input from diverse sources, study minute details, discuss confusing events, and listen intently. Avoid lumping details together or attempt ing to normalize an unexpected event in order to preserve a pre- conceived expectation. 3. Sensitivity to operations. Pay serious attention to minute-to-minute opera- tions and be aware of imperfections in these activities. Strive to make ongo- ing assessments and continual updates. Enlist everyone’s help in fine-tuning the workings of the organization. 4. Commitment to resilience. Cultivate the processes of resilience, intelligent reaction, and improvisation. Build excess capability by rotating positions, creating additional sources of knowledge, and adding new skills. Be mind- ful of errors that have occurred and take steps to correct them before they worsen. Once the fix is made, make every effort to return to a state of pre- paredness as quickly as possible. Be ready to handle the next unforeseen event. 5. Deference to expertise. During troubled times, shift the leadership role to the person or team possessing the greatest expertise and experience to deal with the problem at hand. Provide them with the empowerment they need to take timely, effective action. Avoid using rank and status as the sole basis for determining who makes decisions when unexpected events occur. SOURCE: Weick and Sutcliffe, 2015. in several studies. For example, hospitals ranked highly in terms of mindful- ness practices by their front-line workers also make fewer errors (Vogus and Sutcliffe, 2007a,b). Likewise, in aviation in particular, pilots who perceive a genuine and proactive commitment to safety (a positive safety culture) by their organizations make fewer errors during Line Operations Safety Audits (Sexton and Klinect, 2009). FAA AVS safety officials explained to the committee that, in addition to their voluntary, confidential safety reporting system, they have engaged with a contractor to conduct the annual survey required by Congress, which would be supplemented with follow-up focus groups. Surveys supplemented

SAFETY CULTURE AND ITS ASSESSMENT 39 with focus groups are appropriate beginning steps in safety culture assess- ment, as described in the next section. The details of the survey instrument were not established at the time of the committee’s briefing (January 2022), nor was it made available for committee review before this report was com- pleted. After briefing the committee, FAA officials subsequently indicated that they intended to complete the initial survey by September 2022. Although safety culture is certainly appropriate for organizations and institutions that operate complex technologies in hazardous environments, a question remains as to whether it is relevant to regulators. The academic literature on safety culture has neglected the safety cultures of regulators themselves (Bradley, 2017), but Shein’s formulation of organizational and safety culture is not limited to regulated entities. Indeed, the cultures of regulatory bodies have adversely influenced the behaviors of the entities they regulate, including the International Atomic Energy Agency’s (IAEA’s) conclusions about the contributing causes of the catastrophic failure at the Fukushima nuclear plant.2 A 2018 National Academies report character- izes FAA’s culture as one that inclines toward zero risk and criticized this culture as an impediment to innovation (NASEM, 2018). The more central question is not whether the safety culture concept applies to regulators but instead the nature of the safety culture that the regulator manifests. In addition to its role in ensuring a high level of safety, FAA is perhaps driven to being risk averse due to the scrutiny it often receives in media depictions of accidents, the frequency with which it is audited by Inspectors General and the Government Accountability Office, and by congressional oversight more broadly. At the same time, as noted in Chapter 2, FAA’s mission requires it to balance safety goals while also serving efficiency goals in meeting the demand for air transportation. In support of this mission, FAA has the charter to identify and rank hazards in a rational process using the best available techniques and to manage these hazards appropriately accord ing to their probability and potential consequences. The challenge of doing so becomes all the more difficult as society’s tolerance for accidents has diminished over time, even as society’s tolerance for air transportation delays and disruptions has also diminished and demand for air transpor- tation has increased. This requires the agency to focus its attention—its mindfulness—on prioritizing its efforts on those hazards that are estimated as the most probable and consequential, as informed by everyone’s insight within its organization. 2 IAEA as cited in Bradley (2017).

40 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 METHODS FOR ASSESSING SAFETY CULTURE As noted, the culture of an organization can be difficult to assess, particu- larly the deeply rooted beliefs and values that are taken for granted and not easily identified or articulated.3 In addition, culture tends to be dynamic in response to circumstances, such as changes in leadership, and can vary across departments, locations, and professions. Several methods are used to assess organizational culture, each with pros and cons as summarized below. Regardless of the method selected, an ongoing program of assess- ment can initiate “a set of conversations, decisions and actions aimed at directing organizations toward safer and more sustainable performance” (NASEM, 2016, p. 138). The method chosen should support these reasons for assessing culture: • To move conversation from the vague to the specific—An assessment moves conversations from vague, general perceptions, or a “sense” of how the organization is doing with respect to safety, toward more focused exploration of what lies behind specific and quantifiable metrics, such as accident rates and injuries. For example, if an assess- ment reveals that workers perceive a gap between management pro- nouncements about the importance of safety and management actions that appear to be unsupportive of safety, this finding can trigger a more targeted conversation about what types of management actions (e.g., never committing significant budget dollars to improving safety) are driving this perception and how management can better align its words with its actions. • To allow for the tracking of progress—Without ongoing assessment and communication of its results, employees cannot evaluate the effective- ness of initiatives designed to improve the safety culture and safety management. Regular assessments allow management (and others) to detect and reinforce slow changes in an organization’s culture that may be beneficial to safety, as well as to identify and address slow changes that may produce a drift into failure (Dekker 2011). • To provide motivation and feedback—Ongoing assessment allows individuals throughout the organization to receive feedback, set goals, and seek to improve the organization’s safety management. If its results are sufficiently communicated, it can also help close the communication loop when front-line employees have raised safety concerns (or concerns about work and managerial practices that are not specified as related to safety). Even in the absence of tangible progress, it is important for management to communicate to front-line 3 This section draws heavily from Chapter 5, Safety Culture Assessment and Measurement, in NASEM (2016).

SAFETY CULTURE AND ITS ASSESSMENT 41 employees that they are being heard and that management is investi- gating how to address the issues they have raised. • To identify strengths, weaknesses and gaps, and potential improvements— An assessment spanning different subgroups, functions, and operational areas of the organization can provide an opportunity to examine the consistency of the culture and tailor improvement efforts to specific concerns. For example, different interventions will be needed if senior management is viewed as strongly committed to safety, but front-line management frequently trades off safety for more pressing goals, or if front-line management is viewed as being strongly committed to safety, whereas senior management is more focused on financial performance. • To provide leading indicators—A growing body of research (e.g., Zohar 2010; Morrow et al. 2014) and recent meta-analyses ( Christian et al. 2009; Narhgang et al. 2011) show that safety culture can predict both safety behaviors and accidents/injuries. Assess ments of safety culture hold promise for providing leading indicators of safety issues that can trigger proactive interventions and serve as complements to lagging indicators, such as incident rates. However, this research has focused on personal safety (e.g., use of personal protective equipment, days away from work) rather than process safety;4 therefore, more research is needed to explore the relationship between safety culture and process safety. (NASEM, 2016, pp. 141–142) Unfortunately, across both academic research and reports from multiple industries, there is no single agreed-upon approach to assessing organiza- tional and safety culture (NASEM, 2016, p. 142) or on the concepts or typologies of culture that should be measured. Multiple methods are avail- able and in use for assessing culture, the pros and cons of which are sum- marized in Table 3-2. The committee that prepared the 2016 report recommended: The use of multiple methods [emphasis added] to combine the strengths and mitigate the weaknesses of individual methods in order to achieve a practical mix of benefits without crippling costs. For example, a safety cul- ture or climate survey5 could be used to provide broad background infor- mation and raise questions about dimensions, departments, or hierarchical levels with higher or lower scores. Typically, attention focuses on the lower scores as areas for improvement, but it may be useful to think about 4 Process safety is usually defined as safety management approaches designed to avoid major accidents rather than individual occupational injuries. 5 A climate survey takes many forms, but generally asks employees about their perceptions of the organizations they work for. Some climate surveys probe respondents’ perceptions of their organizations’ values and goals and the alignment of professed values and goals with actions managers actually take.

42 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 TABLE 3-2 Methods for Assessing Safety Culture Method Description Advantage Disadvantage Ethnography (from Anthropology) Deriving meaning and insight from observation and interactions with insiders over an extended period of time. Best able to reveal “deep” culture. Time consuming and expensive. Difficult to replicate. Episodic Field Work and Document Review Direct observations of work practices by individuals or teams combined with analysis of documents. Similar to an audit. Less time consuming than ethnography but less able to reveal “deep” culture. Still fairly time and labor intensive and therefore expensive. Surveys and Focus Groups “Climate” surveys with focus groups in order to understand better the surface impressions (i.e., easily seen or observed) provided from surveys. Less expensive and time consuming than above methods. Standard instruments available. Can be anonymous. Can foster conversations and learning. “Climate” surveys tend to reveal surface features and temporal perceptions. Focus group participants that help interpret the results may not be representative. Guided Self-Analysis Insiders analyze own cultures through facilitated workshops, meetings, and dialogue. Includes “after action reviews.” Good evidence that well-conducted efforts have improved safety in a variety of industries. After action reviews or safety rounds carried out as a duty, rather than a learning opportunity or to assign blame, can be counterproductive. the organization’s strengths and attempt to learn from its successes. It is essential for interpretation of the meaning of the scores to go beyond numerical averages or the intuitions of a few people preparing the survey report. Many organizations use focus group interviews following a survey to discuss its results and to obtain specific examples and details as to what the responses mean to workers, supervisors, and managers. Some organi- zations include work observations (as in episodic fieldwork) conducted around the time of the climate survey to add further richness to the data. Then, diverse teams can begin to assemble ideas about how to intervene and how to evaluate whether progress is being made. This process helps elevate concerns so they receive attention, resources needed to address them are available, and steps are taken to gather further information and

SAFETY CULTURE AND ITS ASSESSMENT 43 TABLE 3-2 Methods for Assessing Safety Culture Method Description Advantage Disadvantage Ethnography (from Anthropology) Deriving meaning and insight from observation and interactions with insiders over an extended period of time. Best able to reveal “deep” culture. Time consuming and expensive. Difficult to replicate. Episodic Field Work and Document Review Direct observations of work practices by individuals or teams combined with analysis of documents. Similar to an audit. Less time consuming than ethnography but less able to reveal “deep” culture. Still fairly time and labor intensive and therefore expensive. Surveys and Focus Groups “Climate” surveys with focus groups in order to understand better the surface impressions (i.e., easily seen or observed) provided from surveys. Less expensive and time consuming than above methods. Standard instruments available. Can be anonymous. Can foster conversations and learning. “Climate” surveys tend to reveal surface features and temporal perceptions. Focus group participants that help interpret the results may not be representative. Guided Self-Analysis Insiders analyze own cultures through facilitated workshops, meetings, and dialogue. Includes “after action reviews.” Good evidence that well-conducted efforts have improved safety in a variety of industries. After action reviews or safety rounds carried out as a duty, rather than a learning opportunity or to assign blame, can be counterproductive. engage broad participation in sense-making and change initiatives (Weick 1979; Carroll 2015). Monitoring of safety culture requires more than an assessment every 2 years through a survey. Periodic surveys and audits are most helpful when paired with other, more regular (monthly or quarterly) assessments. Larger organizations often have a “dashboard” of indicators that are used for various management concerns, including productivity, cost, environ- ment, human relations, and safety.... Increasingly, safety culture is a part of such a dashboard, with multiple indicators being examined regularly. These indicators may include codes for safety outcomes, near misses, problem reports, incident investigation results, employee concerns and suggestions, management walk-arounds, observations of pre-job briefings and after-action reviews, and union concerns. [In Chapter 2 the committee points to other possible indicators that could be monitored by organiza- tions, such as tolerance for routine operational errors, failures in carrying out procedures and policies, failures in compliance, weak monitoring and control practices, missed audits, missed deadlines, and increased staff turn- over (Roux-Dufort, 2009; Williams et al., 2017). Also of concern would be failure to inculcate a reporting culture and inadequate management responses to error reports.] Some of these indicators may be quantitative, others a simple green-yellow-red assessment, and still others qualitative comments. Indicators may assess strengths and positive examples as well as weaknesses and problems. The intent is to keep everyone thinking about safety culture along with other management concerns, and to feed this information into the safety management system for improvement efforts. Given that surveys provide only a partial view of the safety culture of an organization, a more comprehensive assessment often engages a team of specialists who use a combination of tools, such as interviews, document reviews, observations, and focus groups.... Regardless of the final com- position of the assessment team, it is important for several reasons that the host organization retain ownership of both the process and follow-up actions on the recommendations resulting from the assessment. First, if employees perceive that management has outsourced the safety culture assessment (and perhaps the broader problem) to an outside agency or contractor, they may conclude that the organization is not really seri- ous about the issue. Second, the safety culture assessment ultimately will require some actions and changes within the organization. One of the key factors predicting the success of change initiatives is management commitment (Zohar and Luria 2005). Management’s staying involved in and retaining ownership of the assessment process will increase its engage- ment in and commitment to the process and any resulting recommended changes. Third, assessments that are conducted and evaluated closer to the organization’s work processes typically result in more timely feedback and therefore greater flexibility and learning. (NASEM, 2016, pp. 152–156)

44 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 From this review of the state of the art in safety culture assessment, the committee draws key lessons for AVS to apply: assurance of management commitment and responsiveness, organizational ownership of the process rather than complete reliance on outside experts, and use of multiple meth- ods beyond surveys and focus groups. CONCLUSIONS This chapter provides a brief introduction and overview of safety culture theory, best practice in safety culture assessment, and the importance and value of it to FAA. It also discusses the value to the commercial aviation industry more broadly of conducting such assessments and using them to generate precursor measures of organizational commitment to safety. The specific element of the committee’s Statement of Task is to assess and draw on the safety culture survey of FAA’s AVS. Given that FAA’s survey has only just begun, there are limits to what the committee can draw on or say about it at this stage. We can, however, offer some closing observations. The implementation of a voluntary, non-punitive reporting system for AVS employees is an appropriate step, as are engaging an expert contractor to develop and implement the survey and plans to use focus groups as ways of helping engage the workforce in interpreting the results. The value of the effort will now depend on its execution. The design of the survey instrument to gauge employee perceptions about safety culture will be important. There are several well-developed instruments in use, typically referred to as safety climate surveys, which an AVS survey could be based on. AVS would benefit from using a climate survey that probes employee perceptions about how management addresses trade-offs be- tween safety and other organizational goals (Zohar and Hofmann, 2012). More generally, best practice indicates that employees will be more likely to trust and value an effort that has visible and tangible top manage- ment support and participation, which may not be the case if employees perceive that the survey and focus group follow-up is being undertaken merely as an obligation to meet a congressional mandate. Feedback of results and discussion and interpretation of them with focus groups will help discern what they imply about AVS culture and contribute to the value of the effort if done well, as will meaningful responses from man- agement to employee concerns. An important point to bear in mind is that safety culture assessment is an ongoing process of organizational mindfulness and sense making and not simply snapshots taken at discrete points in time using climate surveys. Additional efforts such as use of teams involving employees to interpret results and propose responses and development, and use of a dashboard of indicators shared throughout the organization, would be helpful in this regard.

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