Over the last few months I’ve had an opportunity to reflect on Operational Risk outcomes in the companies that I’ve worked for and consulted to over the years. This reflection has led me to identify a major challenge facing us all – Lost Opportunities.
In particular I am thinking that Accident, Incidents and Near Misses are being handled less well than they could be – which means that as Organizations we are missing a golden opportunity.
Before reading further – I’d ask you to reflect. Has your organization ever made the same (or a similar) mistake twice?
Having investigated hundreds of accidents, incidents and production disasters I’d be surprised if your answer wasn’t yes. I still remember the quote from the lead HSE Investigator on the Piper Alpha disaster – who observed that “There is a terrible sameness in these types of incidents…” alluding to the number of similar incidents that occur before a major loss is suffered.
But – if you can honestly answer that your organisation has never made similar mistakes twice – please leave a comment on this post and share with others how you’re achieving this!
If you only have a few moments – click on the image and it will take you to a summary of the blog post using an interactive web system. All of the post is summarized into a few images, audio and a PDF check list.
Career Highlight – Not Likely!
The vast majority of unwanted incidents that occur in our organizations arise due to Human Error. The human who made the error is typically someone involved in or responsible for the the task / area where the incident occurred – and this generates a challenge for how things are managed after the event occurs.
Observe a child – or reflect on your own childhood. If you make a mistake / break something you’re much more likely to try and hide the fact than come clean and tell a parent / adult!
So – it is Human Nature to try and cover up a screw up. But it is just this behavior that generates a culture of under reporting and leaving one or more latent error conditions that can cause much bigger problems down the track.
Ask yourself these questions:
- Who is responsible for reporting incidents and near misses?
- Is there a department, role or person in charge of confirming the quality and quantity of reports logged?
- Does the number of losses report come close to the expected relationship in the Bird Triangle?
It takes a concerted effort for an Organization to overcome under reporting. A sign you’re winning is when your Organization celebrates its’ successes and looks at problems and incidents as a launch pad to the next successful solution / improvement.
The Pineapple Problem
Many organizations tend to “shoot the messenger” when it comes to reporting problems. Many organisation have Cost Review and similar meetings that get termed Pineapple Meetings – due to the feeling that the purpose is to publicly discipline team members who haven’t hit their targets. An incident in your work area is definitely a part of not hitting a target!
A key factor is how Decision Makers / Leaders react to non conformances – what they do rather than what is written or said.
How does your Organization handle these issues:
- What is the tone of your monitoring meetings (e.g. budget / performance review)? Do they focus on reinforcing what has been done well or do they criticize variances exclusively? Does it feel like a pineapple session to those present?
- Do most of the line and secondary supervisors adopt a Sergent Shultz defense when problems arise?
- Is there a culture of “blame storming” around any problem or incident? Does this come from a history of people being punished whenever they mention a problem or something goes wrong?
It’s a hard thing to look at or admit to – but often the leaders in an organisation need to “Look in the Mirror” to see if problems around under-reporting are being made better or worse by their actions. Achieving that goal of not accepting poor performance AND solving issues which lead to poor performance is ideal – and involves application of good management practices.
Another dimension – which impacts more on what is generated from the analysis of an incident is the way in which Incident Forms are structured and teams are formed. There is a history of wanting to be able to compare Incident records between business units and organisations. This has led to the formation of standards which by and large focus on the description of categories. The categories themselves have come from input from many diverse industries and businesses.
Coming from this are forms and guidance for incident analysis that are:
- Category based – with a focus on the injury sustained when making comparative reports;
- Standards driven – drawing on sources such as AS1885.1 – which “locks in” a requirement for a lot of data that slows down form completion and uses general terms that lead to a lot of “Other” categories being selected by Supervisors who are trying to fill out the form without being familiar with what these categories are meant to mean (they aren’t terms usually included in a firm’s language);
- Strictly channeled through a work flow so that based on severity certain levels of the Company need to be notified within set time frames, and;
- Harder to follow up and build upon.
When the process requires a team to form – for more serious incidents – it is very difficult to find a volunteer. Most members of the firm don’t want to be the one to lay blame on a colleague. Similarly when the incident occurred in your area of control – you may not want to be exposed to ridicule during an analysis of what went wrong.
Complex analysis methods can also generate problems. There are some great, technically sound investigation “tools” commercially available – BUT (and this is a biggy) – if you don’t use them often they can prove very confusing and the team will “bog down” trying to work out how to use the tool. This can really mean that the truth gets lost in the process and the recommendations are more based on the language in the tool – rather than the reality of what went wrong.
Ask yourself these questions:
- Are your Incident Report forms based on an external standard – and as such have kept the language / words that are present in the standard?
- Is there plenty of space and encouragement for providing a good description of the incident – with some guidance about the key point to include for it to be a good description?
- Does the Incident report require quick escalation (see earlier) that requires use of a complex tool?
Another key type of issue that can arise is that of conflicting interests. If it is not in the team member’s interest to uncover problems – which then require extra work to implement solutions – there is a built in chance of failure during the analysis phase of the Incident Reporting process.
Also – familiarity with the circumstances can also mean they are part of the team who have a responsibility for the works at and around the incident. This is certain to move any sane person to minimize the problems identified and fixes required – otherwise they are generating a bunch of thankless tasks for themselves.
Another problem that can arise with gathering teams – particularly when to do a thorough job will take a number of days – is the provision of resources. If you join a team and your own work is stacking up – it can make for a stressful time and encourage speed rather than quality in the accident analysis.
Some challenge questions for how you “deep dive” into understanding why and incident occurred and what to do about it are:
- Is there a clear process for selecting team members – that gathers data from the incident area but doesn’t generate conflicts of interest?
- Are Incidents to analyse in detail selected based on threat to the business (potential for major loss) or severity of the incident (what actually happened)?
- When a person is drawn into an investigation team – is there own work covered to minimize the volume of work they’ll have after the investigation process is completed?
To Sum Up
Reporting and understanding incidents is vital to improving how your business succeeds. Not missing early warning signs and then understanding what controls have failed and why is critical in achieving a high reliability organization.
All organizations could benefit from critically reviewing their approach to Incident management and response – a mission that the ORM team would be only too happy to help with!