TT Talk - I know it is wrong but...
How often is a deficiency found but not acted upon, or an incident occurs, and it is not reported? Loss and near miss reporting has always been a thorny topic, but needs to rise above issues of corporate and national culture.
The importance of learning from incidents is widely recognised – and sits at the heart of TT Club’s loss prevention activity – but increased attention should be given to understanding and acting on ‘near miss’ events. Studies have evidenced a correlation from multiple near misses, through damages to ‘stuff’, to minor injuries and finally major injuries or fatalities. This reasoning supports attention to such leading indicators in order to preclude major incidents that are both distressing and disruptive.
This is an aspect where reviewing what is commonly available in the air industry – the Aviation Safety Reporting System (ASRS) – could be of value. Indeed, the US Coast Guard is reportedly considering revisiting such a confidential near miss reporting system, which relies on those directly involved to submit reports. However, is the surface transport system ready for this culture?
Part of the issue is inevitably behavioural. The Institute of Business Ethics (IBE) has carried out surveys of employee views of ethics at work, both in the UK and Europe. The most recent published report (in 2018) noted that 24% of UK employees had been aware of misconduct at work, of which 35% were recorded as safety violations. However, 33% of the respondents decided not to speak up. The reasons given for not raising their concerns were concerns that it might jeopardise the individual’s job, the belief that no corrective action would be taken or attitudes of indifference (“it’s none of my business”). This analysis is supported by a survey of 1,000 callers to the UK Public Concern at Work whistleblowing advice line, 60% of whom did not report any response from management (negative or positive) after having raised their concerns.
Research into the reasons workers do not speak up about unsafe conditions and work practices has been summarised into nine key reasons why workers don't report near misses.This makes interesting and challenging reading, which goes beyond the pure behavioural aspects.
It would seem that there are two key issues in implementing effective near miss reporting, from which organisations and broader industry may learn: confidentiality and validation. The strength of ASRS is attributed to its voluntary and non-punitive nature. Inevitably, those who report seek some level of anonymity for the reasons mentioned above, but protections generally given to ‘whistle-blowers’ can be quite narrow. Those afforded in the US ASRS scheme prevent access by enforcement agencies in the absence of an actual incident or criminal activity. Thus, in reality, the core issue may be less about anonymity than confidentiality – and this also supports the second requirement of validation.
Of course, there are established industry reporting methods in the maritime mode, such as the Nautical Institute’s Mariners' Alerting and Reporting Scheme (MARS) and CHIRP Maritime (see also a related previous TT Talk article). Both these reporting systems seek to investigate the reported unsafe condition or practice as an independent third party and subsequently provide anonymised reports to industry stakeholders. Similarly, insurers (including TT Club) publish guidance and alerts that arise from experience. Further, there are some national near miss reporting schemes, as well as requirements sometimes embedded in regulations – such as the International Safety Management (ISM) Code.
“ensure that it is possible to learn from the ‘mistake’, meaning that there has to be causal analysis, leading to corrective actions and preventative measures “
Apart from the need to overcome or enhance the individual and corporate culture, it is also important to ensure that it is possible to learn from the ‘mistake’, meaning that there has to be causal analysis, leading to corrective actions and preventative measures. And apart from such responsiveness, the industry faces the legal and commercial challenges of sharing more broadly.
Developing a robust culture, engaging with broad stakeholders (including enforcement agencies), in which near misses are viewed as learning experiences rather than a cause for punitive action, will serve the current and future industry well. Promoting a ‘positive error management climate’, dealing with these as leading indicators, could protect lives, assets and the environment, and materially improve overall performance.
We gratefully acknowledge the assistance in the preparation of this article of Bill Brassington of ETS Consulting