Identifying Risk via Confidential Reporting Systems

RAe Soc HF Group EMSG Conference, 10th October 2007

Dr Mike Rejman
Director, CIRAS

Recent Career 1988 - present
 Head of Human Factors Unit, UK Army Air Corps (accident investigator, set up their confidential reporting system)  Principal Consultant, DERA, QinetiQ,  Assistant Director of Patient Safety at National Patient Safety Agency (accident investigation training, reporting system, risk assessment)  Director of CIRAS, the confidential reporting system for the UK railways

Understanding the Problem
• ~ 80% of accidents are attributable to human factors issues, at the individual level, the organisational level, or more commonly both • This is probably a conservative figure, and is irrespective of domain • To manage this we need to identify and understand the risks • Without this understanding we can‟t put appropriate remedial action in place

Reason‟s Swiss Cheese Model
Organisation and processes - Deficiencies

“Latent failures” - precursors, preexisting enabling conditions
“Active failures” (skill, rule and knowledge errors)

Multiple Defences

Accident or incident

The Accident Iceberg (Heinrich, Bird, and others)

1 ? ?
near misses
often unreported

serious incidents



& concerns

Prior Indicators of Risk
• Herald of Free Enterprise, 1987
– Numerous accounts of previous sailings with the bow doors open – Economic pressures to spend less turnaround time in port

Prior Indicators of Risk
• Challenger Space Shuttle
– Ample previous evidence of seals shrinking in cold temperatures

– Voiced by some engineers
– Political pressure to launch

Prior Indicators of Risk
• Kings Cross Fire, 1987 – Numerous fires, bundles of rubbish and wooden escalators with greased tracks, some records but nothing done

– Complacency and no system to evaluate risk

Prior Indicators of Risk
• Hillsborough, 1989
– Two Police Officers on horseback prevented similar incident the previous year by blocking access to the same terrace area – No organisational memory

Investigating Accidents with the Army Air Corps
• Experience while conducting investigations indicated that the workforce held lots of important information that could have been used to prevent the accident

• The culture didn‟t encourage reporting and there was no „safe‟ route for this information to be passed on and assessed

AAC views on confidential reporting
• (Some) Senior Command
– Blame & punishment – Would subvert the chain of command

• Others
– System required – RAF-run Condor system inappropriate

AAC maintenance issues
• Gazelle maintenance team change
– habit, slip

• Lynx tail rotor gear box problem and cannibalisation
– culture, knowledge error, perceptual problem, assumptions (some of these issues could have emerged via a confidential reporting system)

The situation in the NHS
Prof Sir Liam Donaldson, CMO England
• „Organisation with a Memory‟ (2000)

National Patient Safety Agency formed (2001)
NHS Staff views – e.g. Primary Care – Pharmacists – GPs – Dentists

Patient safety risk
18 16 14 12 10 8 6 4 2 0 % of acute admissions Australia 16.6% England 10.8% Denmark 9% New Zealand 12.9% Canada 7.5% Japan 11% France 14.5%

The situation in the NHS
• The NHS is a labour-intensive industry
– leading to a large number of human interactions – increasing the risks of decision-making errors – and increasing the risk of communication errors

The national reporting and learning system • Positive:- the system now has over well over one million reports • Negative:- however the quality of much of the data is not high • The system was originally set up to be anonymous, rather than confidential

NHS example
• ~ I30 types of infusion pump available • Study revealed that 47 different types were present in one Trust • And 6 different types were found on one ward • Leading to high level of performance errors

NHS examples
• Removal of the wrong kidney • Chemotherapy drug vincristine delivered intrathecally instead of intravenously

Rail Confidential Incident and Analysis System
• • • Pilot study in Scotland 1996 Rolled out nationally after Ladbroke Grove accident and Cullen Inquiry 2000 3 regional offices run by contractors, now one in-house team in London In 10 years of operation there has never been a breach of the confidentiality guarantee for reporters

UK Rail
• Is one of the safest forms of transport both for travellers and staff • But it could be even safer as the accident in Cumbria in February showed

CIRAS reports on non-compliance with rules
Forms of non-compliance across all sectors (2004 - 2006)


Intentional rule violation 51.0% Best practice ignored Rule violation 31.4%

Non-compliance by sector
Forms of non-compliance by sector (2004 - 2006)
10 9 8 7

No. of reports

6 5 4 3 2 1 0 NR Subcontractor Sector TOC LUL

Intentional rule violation Rule violation Best practice ignored

Causal factors for each sector
Sector Cause 1 Cause 2 Cause 3

Network Rail

Performance before safety


Poor planning


Poor management


Subcontract - or to NR TOC

Inadequate training


Staff shortages


Performance before safety


Performance before safety




Inadequate training



Performance before safety


Staff shortages


Poor management


Quotes from reporters
“ We‟ve refused to do the job on the grounds of safety … …. and we‟ve been threatened with disciplinary action...”

“I‟ve been told that if I didn‟t want to do the job [on safety grounds] then I shouldn‟t bother coming to work tomorrow”

How can we best identify risks?
• Reactive/retrospective
– – – Accidents and incident investigation Root Cause Analysis (what, who, how, WHY) Reporting systems: incidents

But we need to move people from „fire-fighting‟ the last error to trying to prevent the next one Proactive/prospective
– – Confidential Reporting systems: near misses, and safety concerns Hazard identification, and prospective risk assessments

Barriers to Reporting
• • Fear (including concerns re confidentiality) – blame culture, job loss, commercial issues Practicalities – time to report – complex forms Ignorance – what to report (definitions e.g. „near miss‟) Apathy – lack of perceived benefit to individual vs potential cost – lack of faith in the system to change things – lack of any feedback („black hole‟ syndrome)

Reporting rates and triangulating risk
• For these reasons, incidents, near-misses & safety concerns will always be under-reported whatever the system But there are ways to increase reporting, by targeting specific issues, and seeking other ways to triangulate risk including surveys

Reporting rates and triangulating risk
• More reports = good news, not bad news. With more information to analyse we can act as an Early Warning System The industry must therefore encourage and reward reporting, not penalise it

CIRAS has recently moved beyond the model of the „passive post-box‟ and is seeking to be more „proactive‟ in engaging industry groups e.g. with workshops and surveys

Confidential Reporting Systems
In an ideal world we wouldn‟t need confidential reporting systems. Staff would be happy to volunteer information about errors they made, or safety concerns they had, without fear of blame or victimisation, and management would willingly address all the issues raised by their staff…………

Confidential Reporting Systems
But we don‟t live in an ideal world !
Consequently in virtually all safety-critical industries, here and abroad, it has been necessary to incorporate confidential reporting systems as part of the suite of reporting systems available and operating within safety management systems

Identifying Risk by Donald Rumsfeld
As we know, there are known knowns. There are things we know we know. We also know there are known unknowns. That is to say We know there are some things we do not know. But there are also unknown unknowns, The ones we don‟t know we don‟t know.

Confidential reporting systems
• Are there to access all these categories • Are an indispensable part of the process of identifying risk in any safety-critical industry • Should be an integral part of any safety management system

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