Reporting the Right Events in the Right Way

Just reporting the right events, whether they be incidents or activities, is only a small aspect of getting better data to based decisions. Reporting them in the right way is critical to developing a responsive improvement cycle.

It is fairly simple to recognise a three-stage reporting model for “events” that centre around risks encounters. In practical terms the life-cycle of a risk is the essential mechanic that governs this model. We identify the risk, we record when it was encountered without harm, and we record it where it was encountered and harm was incurred.

Risk identification occurs at any point in time when a set of circumstances (unsafe conditions, unsafe act, organizational behaviour) creates or has the potential to create a situation in which harm might occur. This process results in profiling the risk, which consists not only of generically describing it, but using some scale to identify its potential impact. When done this is a powerful first step to prevent the manifestation of impacts that harm the company or workers; but identification is not worthwhile unless the process is adhered to in a consistent way, which makes risks capable of comparative analysis. In a simple example, a risk of a paper cut is likely to have a fairly low harm factor, whereas a risk of being crushed by a dump truck is probably going to present serious harm to whoever encounters it. If your risk profiles are not comparable (ranked on the same scales), there is no way to direct resources by priority based upon critical impact.

Recording risk identifications is about ensuring that we know about a risk factor before it has manifested, preventing any impact on the company or a worker. Whether we detect the risk encounter via an inspection or an event investigation, what we are doing by recording it is to give us a broader base to analyse it. Recognising the risk encounter builds a record of its occurrence rates and their context, and that allows preventative enhancement. It focused personnel on both the common risks, and helps them ask two important questions: why is this risk so commonly encountered; and what will happen if it manifests harmfully? Knowing the answers to those questions means resources are applied to manage threat conditions rather than arbitrarily. Extending the example of paper cuts and dump trucks crushing folks, we might find that paper cut risk occur with significantly greater frequency. Basing operations on a purely traditional model, pretending near misses are recorded dutifully, we would eventually have that count reach some number that triggers resources poured into developing awareness. Meanwhile, the two near misses with the dump truck will be ignored by raw count. But comparing the impact, potential for harm, it is immediately evident that the first near miss of the dump truck is likely to garner immediate attention, and controls will be enhanced to avoid that risk developing into a full blown fatal incident. The defensible provision of ranking in this regard is part of the process that makes near miss recording so valuable.

High impact incidents, where harm is incurred, are always reported, and the process is fairly straightforward with some variations for context within an organisation. The majority of reports are always generated in the field, and flow upward to safety personnel and then beyond. At this stage the classification model comes into play heavily, with a special focus on the outcome potential. At a human level we know what can kill us is always treated with more serious regard than what can make us sneeze a single time. What is vital in this process model is that the process doesn’t end when legislation allows, because the feedback cycle is where the actual constructive value extends from. The analysis on the controls that failed becomes a foundation element for analysis of systemic failures, and it is the mechanism whereby control enhancement is triggered. If the process ends when the report is filed, the process fails.

The primary goal of reporting is to record, and the primary goal of risk-management is to analyse the recorded data. Form-filling tools produce paper, and risk-management systems produce improvements by way of cyclic improvement. Only cyclic improvement creates positive change, cost suppression opportunities, and drives productive improvements.