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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

HFACS and Wildland Fatality Investigations

Hugh Carson wrote this article a few days after the Cramer Fire

Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report

A Roadmap to a Just Culture: Enhancing the Safety Environment

Cover and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form

Rainbow Springs Fire, 1984 — Incident Commander Narration

Years Prior
April 25th
Fire Narrative
Lessons Learned

U.S. Forest Service Fire Suppression: Foundational Doctrine

Tools to Identify Lessons Learned

An FAA website presents 3 tools to identify lessons learned from accidents. The site also includes an animated illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."

A Roadmap to a Just Culture:
Enhancing the Safety Environment

Prepared by: GAIN Working Group E,
Flight Ops/ATC Ops Safety Information Sharing

First Edition • September 2004

Appendix A. Reporting Systems

This section describes attributes (not necessarily mutually exclusive) of mandatory, voluntary, and confidential reporting systems (from Gordon, 2002).

A1. Mandatory accident and incident systems

The traditional method of recording accidents is by using a mandatory system that companies and regulatory bodies manage. One of the main reasons for the mandatory recording of accidents is for legal and insurance purposes, although their purpose is also for learning and prevention of similar incidents. However, a difficulty with learning from such types of information is that people are possibly more reluctant to disclose the whole story, because of their reluctance to take the blame for the incident. The other problem with such systems is that because there are not large numbers of accidents to record, high potential incidents are also included. Mandatory reporting of incidents means that few will be reported because many incidents go unnoticed and therefore it is difficult to enforce (Tamuz, 1994). Mandatory incident systems are reinforced through automatic logging systems in aviation (e.g. the Black Box system) and the railway industry (e.g. Signals Passed at Danger, SPD); however, the recording of incidents still depends on reporting by the individual worker (Clarke, 1998).

A2. Voluntary incident systems

Voluntary reporting forms are submitted by the reporter without any legal, administrative or financial requirement to do so (Chappell, 1994). In such a system, incentives to report may be offered (such as fines and penalties waived) and the reported information may not generally be used against the reporters. The quality of information received from voluntary reports is generally higher than from mandatory systems, mainly because people who report into voluntary systems do so because they want to see a safety issue pursued. ASRS is a voluntary system and the number of reports depends on the publicity; politics; and perceived reporting incentives (Tamuz, 1994).

A3. Confidential accident and incident systems

In order for any workforce to feel 100% comfortable about reporting incidents and accidents to management, an exemplary open reporting culture is required. However, does such an organization exist? O'Leary (1995) believes that in an environment in which the safety culture is not exemplary, for example where a reporter may fear (rightly or wrongly) that they may be disciplined, confidentiality is a necessity. So, how do companies know when they need a confidential system?

A3.1 The process of confidential reporting

The main purpose of confidential reporting systems is to allow companies to collect larger quantities of information and more detailed accounts of accidents and incidents. In addition, confidential reporting programmes allow incidents and hazardous situations to be picked up early on, so that alerting messages can be distributed to personnel on other installations. Furthermore, this information can strengthen the foundation of human factors safety research, which is particularly important since it is generally conceded that over two thirds of accidents and incidents have their roots in human and organizational errors.

Confidential reporting programmes allow personnel to report their errors or safety concerns to an independent ‘safety broker’. This safety middleman assesses a report, where appropriate draws it to the attention of the operator and safety authority and over time, builds up a database which can be used to detect safety trends or to change training or procedures. Companies that recognize and support such data collection systems accept that human beings do not like telling their superiors about their mistakes or those of their workmates.

Confidential Accident Reporting Systems protect the identity of the reporter. Reports may or may not be submitted anonymously to a confidential programmed. If the identity of the reporter is known at the time of submission, it enables further details to be collected if necessary. The identity of the reporter is either removed or protected from distribution. Voluntary confidential incident reporting programmes promote the disclosure of human errors, provide the benefit of situations described with candid detail, and enable others to learn from mistakes made. Voluntary systems may also produce a higher quality of reporting from individuals motivated by a desire to see an issue pursued.

By protecting the identity of individuals or organizations, confidential reporting systems make it possible to gain the support of the industry and promote incident reporting. ASRS assures confidentiality by eliminating any information that could identify the flight and the airline, allowing them to gather valuable information about incidents, especially regarding the human factors, which is normally difficult to obtain from other sources. Guarantees of confidentiality are ineffective if the organizational conditions enable supervisors or co-workers to deduce who reported a potentially hazardous situation (Tamuz, 1994).

A3.2 Examples of confidential reporting systems

Since the ASRS system was developed in 1978, many aviation regulatory bodies have followed suit in Britain (CHIRP), Australia (CAIR), Canada (CASRS) and South Africa (SAASCo). The British confidential aviation system, CHIRP, which is held by an independent charitable organization, was introduced after it was found that pilot errors were significantly under-reported by pilots making the reports. Pilots can make complaints into the system about unsafe or illegal practices by their employers and it provides evidence of incidents which would otherwise remain unreported, such as ergonomic deficiencies and breaches of discipline.

Other industries, such as the UK railway industry, have introduced a confidential reporting system (CIRAS) which is operated by the Centre for Applied Social Psychology at the University of Strathclyde. In addition, the US Nuclear Regulatory Commission (HPES), petrochemical processing and steel production (PRISMA), US Navy and US Marines (HFACS) and health care (MERP) have confidential reporting systems in place. Many of these confidential reporting systems have been found to have a direct impact on changing the company’s systems, such as introducing new training or redesigning equipment.

The Nuclear Regulatory Commission introduced a human factors confidential reporting system (HPES) in which no penalties are associated with reporting non-consequential events or ‘close calls’. In the highly charged, political, financially accountable and legal environment of nuclear power, this system was backed by communal pressure and became institutionalized and effective across the industry. The intensified approach to process improvement led to financial gains through more efficient power production (fewer outages, shutdowns, reduction of capacity). The confidentiality and other protections within the system increased in proportion to the sensitivity, value and difficulty of obtaining the desired information (Barach & Small, 2000).

In addition, airline companies, such as British Airways, have implemented their own inhouse confidential reporting systems (HFRP) into their overall safety systems. In British Airways, the benefits of confidential reporting systems have been demonstrated in the increase in information collected from their confidential reporting form (Human Factors Report), compared to their mandatory reporting form (ARS), where they believe the Human Factors Programmed allows a freer and more complete level of reporting by flight crew.

Berman & Collier (1996) surveyed 50 companies (power generation; aviation; rail; marine transportation; onshore and offshore oil & gas; petrochemical; manufacturing; food & drink) incident reporting systems. The companies used a range of reporting systems such as anonymous, no-blame reporting, ‘in-house’ and ‘third-party’ confidential reporting schemes. The majority of organizations who had confidential reporting systems used ‘in-house’ systems as opposed to ‘third-party’, and where ‘third-party’ systems were used, they are usually used in addition to the in-house systems (Berman & Collier, 1996). Anonymous systems existed in many, but not all companies, and even though all of the companies expressed a desire for a culture which obviated its need, they accepted that it was probably not attainable. The majority accepted the need for a hotline, such as the UK Health and Safety Executive Hazard Hotline.

In another survey of confidential reporting systems, two thirds of the 12 reporting systems examined by Barach & Small (2000) were mandated and implemented by federal government with voluntary participation, over three quarters were confidential and all used narrative descriptions; most offered feedback to their respective communities; some offered legal immunity to reporters as long as data were submitted promptly (e.g. up to 10 days after the event for ASRS).

How can companies transform the current culture of blame and resistance to one of learning and increasing safety? Barach & Small (2000) answered this question with the following three points: (1) by understanding the barriers and incentives to reporting; (2) by introducing norms that inculcate a learning and non-punitive safety reporting culture in training programmes and (3) by reinforcing legal protection for reporters. High risk industries have shown that implementation of incident reporting systems are essential as they benefit their organization more than they cost the organization.

A3.3 Disadvantages of confidential reporting systems

Not all companies and safety researchers believe that confidential reporting systems are necessary. Berman & Collier (1996) criticized confidential reporting systems by stating that the value of confidentiality or the need for no-blame system may not be entirely appropriate, where an overemphasis on confidentiality may hinder companies moving toward an open reporting culture, as it implies that reporters may need to be protected from management.

In addition, other researchers have stated that confidential systems are difficult to validate objectively and it can be difficult for management to accept information from people who wish to remain anonymous (especially managers who are not committed to human factors reporting). However, without such systems organizations may miss the genuine concerns of crews (O'Leary, 1995). Other limitations of confidential reporting systems are described within the following section.

This section has described some of the ways of collecting detailed information about accidents and incidents, particularly focusing on confidential reporting systems. Industries have found that immunity; confidentiality; independent outsourcing of report collection and analysis by peer experts; rapid meaningful feedback to reporters and all interested parties; ease of reporting; and sustained leadership support are important in determining the quality of reports and the success of incident reporting systems. The following section describes the steps that need to be taken to implement a confidential reporting system and some of the pitfalls that can occur.

A3.4 Legal aspects of confidential systems

The rationale for any reporting system is that a valid feedback on the local and organizational factors promoting errors and incidents is far more important than assigning blame to individuals. To this end, it is essential to protect reporters and their colleagues as far as practicable and legally acceptable from disciplinary actions taken on the basis of their reports. But there have to be limits applied to this indemnity. Some examples of where the line can be drawn are to be found in: “Waiver of Disciplinary Action issued in relation to NASA’s Aviation Safety Reporting System” (see FAA Advisory Circular AC No. 00-46D Aviation Safety Reporting Program); FAA 14 CFR part 193 – Protection of Voluntarily Submitted Information.

One way of ensuring the confidentiality protection and fulfilling the EUROCONTROL
Confidentiality and Publication Policy is to be found in SRC WP.9.4 “Safety Data Flow” Progress report submitted by SDF-TF. The experience gained in the last three years showed that the EUROCONTROL Confidentiality and Publication Policy is functioning and States have started to gain trust in SRU/SRC. This has to be kept in mind and the reporting chains should not be jeopardized and compromised by deviation from the mentioned policy.

<<< continue reading—A Roadmap to a Just Culture, Appendix B. Constraints to a Just Reporting Culture >>>

Reprinted by permission from the Global Aviation Information Network.


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