Module 9.9–9.10 — Safety management, just culture and the Dirty Dozen

What's new

Regulation (EU) 2023/989 restructured the end of Module 9. The old 9.9 "Hazards in the workplace" has gone; the EASA syllabus now has 9.9 Safety management and 9.10 The 'Dirty Dozen' and risk mitigation, both at level 2 for every category. 9.10 carries one of the largest question allocations in Module 9. (UK CAA Module 9A/9B still uses the older list, but the Dirty Dozen and safety culture are standard UK essay material too.)

9.9 Safety management

Risk management

• Hazard: a condition or object with the potential to cause harm (e.g. hydraulic pressure on a disconnected actuator, a fuel leak, a slippery wing).
• Risk: the combination of the likelihood (probability) of harm and its severity. Risk is often assessed with a risk matrix (likelihood × severity) to decide whether it is acceptable, tolerable with mitigation, or unacceptable.
• Process: identify hazards → assess risk → mitigate (eliminate, reduce, control) → monitor effectiveness.
• Hierarchy of control: eliminate the hazard → substitute → engineering controls (guards, interlocks) → administrative controls (procedures, training, warning signs) → personal protective equipment (last resort).

The Part-145 management system (145.A.200)

The organisation must establish a management system including:

1. clearly defined accountability, with direct safety accountability of the accountable manager;
2. a safety policy and safety objectives;
3. hazard identification, risk evaluation and mitigation, and verification that mitigation works;
4. trained and competent personnel;
5. documented key processes;
6. a compliance monitoring function with feedback of findings to the accountable manager.

It is scaled to the size and complexity of the organisation. GM maps these to the four ICAO SMS components: safety policy and objectives, safety risk management, safety assurance, safety promotion.

Occurrence reporting

• Mandatory reporting: Regulation (EU) No 376/2014 and 145.A.60 require the organisation to report to its competent authority and to the design approval holder any safety-related event or condition that endangers or could endanger an aircraft, its occupants or any other person — in particular any accident or serious incident. Reports go also to the organisation responsible for the aircraft's continuing airworthiness (or the customer for components).
• Timescale: as soon as practicable and in any case within 72 hours of becoming aware of the occurrence (Reg. 376/2014 Art. 4; also stated in 145.A.60(d) for non-EU organisations), with follow-up reports when actions are identified.
• Voluntary reporting: anything else staff believe is a safety issue — near misses, hazards, errors that were caught.
• Internal safety reporting scheme (145.A.202): must allow collection and evaluation of reports (including errors and near misses), identification of adverse trends, investigation and feedback to reporters, while protecting confidentiality.

Safety culture and just culture

• Safety culture — the shared values, attitudes and behaviours about safety in an organisation. Reason's components of a good safety culture: informed, reporting, just, flexible, learning.
• Just culture — front-line staff are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but gross negligence, wilful violations and destructive acts are not tolerated. Reg. 376/2014 sets the EU just culture principles; 145.A.200 AMC requires the safety policy to commit to them.
• A blame culture drives errors underground; a no-blame culture can tolerate reckless behaviour — just culture is the balance between the two.

Key fact: Just culture ≠ no-blame. Honest errors are not punished; gross negligence and wilful violations are.

Identifying, avoiding and reporting hazards

• Hazards in the workplace: moving aircraft and vehicles, engine intake/exhaust zones, propellers and rotors, high-pressure systems, electrical power, fuel and fumes, working at height, confined spaces, noise, chemicals, radiation (radar, X-ray NDT).
• Avoid: follow safety procedures, use warning tags/lock-outs, PPE, barriers, safety pins and collars.
• Report: tell supervisors, use the internal reporting system; record defects in the tech log.

The organisational human-factors programme

Elements listed in the syllabus:

Element	Purpose
Professionalism and integrity	Doing the job right even when no-one is watching; never signing for work not done or not checked
Error-provoking behaviour	Recognising behaviours (rushing, working from memory, ignoring procedures) that make errors more likely
Reporting errors	Staff encouraged to report their own and others' errors without fear
Disciplinary policy	Clear, published, consistent with just culture — states what is and isn't acceptable
Error investigation	Finds why (contributing factors), not just who; tools such as MEDA (Maintenance Error Decision Aid)
Action to address problems	Fix systemic causes — procedures, training, tooling, staffing
Feedback	Tell staff what was found and what changed — keeps reporting alive
Assertiveness	Speaking up clearly and respectfully about safety concerns

Dealing with emergencies

Know the emergency procedures: alarm and evacuation routes, fire extinguisher types and locations, first aid, spill response, reporting chain. In an emergency: raise the alarm, make the area safe if you can do so without risk, help others, follow instructions. Fuel spills, engine fires during ground runs and injuries are typical maintenance emergencies.

9.10 The Dirty Dozen and risk mitigation

The "Dirty Dozen" were developed by Gordon Dupont (Transport Canada, early 1990s) as the twelve most common human-factors causes of maintenance error. The EASA syllabus lists them in this order:

#	Dirty Dozen item	What it means	Safety nets (risk mitigation)
1	Lack of communication	Failure to transmit, receive or provide enough information to complete a task	Use logbooks/work cards and handover sheets; read-back; never assume; say the important point first and repeat it at the end
2	Lack of teamwork	Failure to work together towards a shared goal	Discuss how the task will be done; ensure everyone understands and agrees; trust and support colleagues
3	Lack of assertiveness	Failure to speak up or express concerns	Express feelings, opinions and concerns respectfully; refuse to compromise standards; give facts
4	Complacency	Over-confidence and self-satisfaction from repetition, losing awareness of danger	Expect to find faults; never sign for what you didn't do or check; use checklists
5	Fatigue	Physical or mental exhaustion threatening performance	Recognise symptoms in yourself and others; plan to avoid critical tasks at the low point; ask for checks; sleep and exercise
6	Stress	Physical, chemical or emotional tension	Take a rational approach to problems; take short breaks; talk to someone who can help
7	Lack of knowledge	Shortage of training, information or ability to do the task	Use current manuals; ask when unsure; get type and recurrent training
8	Lack of resources	Not enough people, tools, equipment, parts, data or time	Order parts early; have a plan for loan/pool parts; report shortages; don't improvise
9	Lack of awareness	Failure to recognise a situation, understand it and predict the results	Think "what if?"; check for conflicts with existing repairs/mods; ask a colleague to check
10	Distraction	Anything that draws attention away from the task	Finish the task before switching; when interrupted, mark the point reached and go back three steps on return; use a checklist
11	Pressure	Real or perceived forces demanding high performance, often time	Communicate concerns; ask for help; put safety first — say "no" when necessary
12	Norms	Expected but unwritten rules of behaviour ("the way we always do it")	Existing norms don't make procedures right; follow the approved procedure; identify and eliminate negative norms

Key fact: The FAA describes distraction as the number-one cause of forgetting things. The standard counter-measure after an interruption is to go back three steps in the procedure before continuing.

Risk-mitigation methods (general)

• Safety nets — personal and organisational barriers against each Dirty Dozen item (table above).
• Checklists and procedures used every time, not from memory.
• Independent inspections and functional checks for critical tasks.
• Tool control (shadow boards, tool tags) to prevent FOD.
• Fatigue risk management: shift design, rest periods, reporting fatigue.
• MRM/HF training and recurrent training every 2 years.
• Occurrence reporting and just culture to learn from errors before they become accidents.