Incident management is an unpleasant fact of life – as the popular phrase (almost) has it, “it happens”. When “it” happens – and “it” might be an adverse event, a near miss or even a potential event – what matters is that someone can report it, so that it can then be followed up and prevented from happening again.
Incident management is an unpleasant fact of life – as the popular phrase (almost) has it, “it happens”. When “it” happens – and “it” might be an adverse event, a near miss or even a potential event – what matters is that someone can report it, so that it can then be followed up and prevented from happening again.
However, in some organisations, someone may not report an incident for fear of reprisal, particularly where an incident involves a colleague or a manager. This then has a knock-on effect in terms of safety, in that incidents that should be reported in order to be followed up aren’t, which increases the risk of their recurrence and prevents the organisation from learning from them.
The importance of a just culture
One element of a just culture is an organisation’s willingness to learn from:
- Errors
- Incidents
- Accidents
In a just culture, an organisation is able to say and hear the unsayable and in which the attribution of blame – not accountability – can be avoided, but instead be willing to learn how it can address and resolve such things. In some organisations, someone may not report an incident for fear of reprisal, particularly where an incident involves a colleague or a manager.
One perspective on open incident reporting systems comes from the UK rail industry, in which the Confidential Incident Reporting and Analysis System (CIRAS) is used in gathering and collating safety-related data. The system was developed in 1996 at the Centre of Applied Social Psychology (CASP) at the University of Strathclyde, under the directorship of Professor John Davies.
‘The main objection to the system came from managers, who were often unhappy about a third-party knowing things they didn't know about themselves,’ recalls Professor Davies. ‘They thought the reports should be going to them, not to us and often felt very strongly about that. ‘However, this sentiment reflected a lack of realisation that CIRAS was getting reports that would never have been sent to managers, and that they would never have known about if it wasn't for the system.’
The role and challenges of the honest broker
The incident reporting system was set up in response to a report on the role of human factors in the railway industry and the Centre acted as an honest broker between rail staff and managers in receiving incident reports relating to rail safety, which they then often followed up with reporters in order to understand incidents and their context.
In terms of reporting systems, the use of an honest broker is interesting from a couple of perspectives. First, for a reporter, a third party’s impartiality may be taken to mean a greater likelihood of action being taken, either directly or indirectly, to follow up incidents and prevent them from happening again.
In contrast, a reporter may see there being a greater likelihood of reprisal, rightly or wrongly, in reporting an incident to management, instead of or as well as any corrective and/or preventive action.
There are things that potential reporters will never tell management for fear of reprisal, including:
- Eroded practices which have become normalised
- Personal errors
- Things you ‘got away with’
These then only come to light in the wake of the latest or next disaster, which isn’t an effective way to learn.
Second, for management, in receiving a report of an incident, middle management have a responsibility to put the incident within the broader context of the organisational culture, which may include:
- Disciplinary action for staff
- Potential reduction in performance for the organisation
There is also the fear that reporting incidents to a third party, rather than management, slows down the investigative process. This could be seen to increase the risk of an incident happening again or becoming more serious. Another common worry is that some third parties might know information about the organisation that management don't know about themselves and that when things come to light, middle management will be seen as presiding over potential disasters by top management – and blamed accordingly for not knowing. However, the crucial point is that these are things they would not be told at all. By accepting the risk of not knowing, top management can assuage that fear to encourage a more open and honest reporting culture.
Implementing an incident reporting system
The use of an external third party in administering a confidential reporting system requires top management to recognise two things: First, in committing to such an approach, they’ll hear things that they don’t want to hear; and second, they’ll also hear things that they’ve never heard before and – crucially – would never hear otherwise.
This has implications for any incident reporting system in which the third party may be a regulatory agency and therefore, as part of the larger organisational structure, perceived to be less impartial than, for example, an academic institution. The challenge for organisations is in taking this from an ideal to a reality, as well as in acknowledging how organisations do work, rather than how they should work. In this, a confidential reporting system should provide an infrastructure.
Professor Davies states: ‘The decision to take CIRAS on board at its inception in 1997 was made by the top managements of the volunteer companies, including ScotRail, Railtrack Scotland, GNER, Virgin and EWS Freight and GT Rail Maintenance, who were all really great.’
In October 1999, 31 people died and 417 were injured in one of the UK’s worst rail accidents when two trains collided at Ladbroke Grove in London. In 2000, in response to the crash, UK Deputy Prime Minister John Prescott mandated that all UK mainline rail come under CIRAS.
‘When the system was mandated UK-wide in 2000, it inherited a load of companies who had not bought into it and didn't want it,’ remembers Professor Davies. ‘For a reporting system to be effective, top management have to want it, understand what its properties are, and buy into it.
‘Confidential reporting systems are very delicate systems and it only takes a word from the wrong source in a particular company or organisation to scupper the whole thing as far as that entity is concerned.’
Do you use an honest broker in your incident management process? What impact has it had on safety management?
Andrew O'Hara
18 years' experience of working with Ideagen, including 16 years of marketing.