A question we are often asked at CIRAS is how confidential reporting actively contributes to the reduction of safety risk in its member organisations. We know from the responses that once a confidential report is assessed on its own merits by those responsible for safety, changes are made at root level. Improvements are often made to their safety management systems, too. Interventions include addressing substandard practice, the provision of more effective training and briefing, changes to safety procedures, and even improvements to problematic roster patterns.
A mature organisation, one with a strong safety culture, will respond not simply because their interest has been piqued, but because their safety conscience has been stirred. In the right mind-set, the questions asked at this point tend to be: ‘How can we make this organisation even safer around here?’, and ‘How can we use the opportunity the report provides to learn?’ Whether a confidential report is perceived as an opportunity, or indeed a threat, is naturally in the eye of the beholder. Mature organisations will want to exploit every opportunity to learn from potential, and actual incidents.
Underpinning the right mind-set is a set of beliefs about whether or not confidential reporting can make a tangible difference to safety. Some of the key beliefs that play a part in determining how effective a confidential report will be at mitigating safety risk in a given organisation are listed below.
1. People who report confidentially are ‘good apples’ In our experience, the overwhelming majority of reporters who choose the confidential route are ‘good apples’. They usually have the right balance of skills, knowledge, experience and attitudes to flag up safety risks appropriately. In other words, they are conscientious, and care about the safety of their colleagues, as well as the general public. Paying close attention to the detail provided by the source of confidential reports, knowing that reporters are correctly motivated, is a defining attribute of the right mind-set. The alternative way of thinking is to view reporters by default as ‘bad apples’, or ‘troublemakers’, but that is counterproductive in that it likely leads to the dismissal of critical information. Viewing reporters as sources of organisational wisdom opens the door to new thinking.
2. Confidential interviews allow ‘deep dives’ into culture Rightly or wrongly, not everyone is comfortable talking to their line manager about safety. And there isn’t always the time to analyse what is going well, or not so well, in the working environment. When reporters are interviewed confidentially, there is the time and space away from work to expand on the various factors that may affect the safety of the job they are doing. Asking the right questions in an interview makes it possible to ‘deep dive’ into an organisation’s safety culture, retrieving information that might otherwise remain buried. A new perspective is often offered by the unearthing of information, supplied in the context of a confidential interview, which can shed new light on an old problem.
3. Blind spots are uncovered by confidential reporting Organisations normally have a clear idea of what information they are prepared to disclose in the public domain. Then there is information an organisation keeps for internal consumption only, preferring to withhold it from the outside world. These two areas are under the organisation’s control. But reporters may also confidentially raise a safety issue which is in the organisation’s blind spot. An ‘off the radar’ safety issue like this could potentially cause an accident, but management - through no fault of their own - may be unable to see it. Staff closer to the action on the ground may have a much clearer view of the risks, reporting confidentially what they experience as a real risk, but is not being taken seriously enough. Responded to correctly, a confidential report can help illuminate the concern in the blind spot.
4. Accidents can be prevented by confidential reporting The ‘holy grail’ of confidential reporting is to prevent an accident. It is very difficult to prove an accident didn’t happen because of a confidential report. Confidential reporting deals in potentials and sometimes points to low probability, high impact events. These can be referred to as a ‘black swan’, a term coined by Nicholas Taleb (2008) in his book of the same name. Conventional data analysis may not pick up all the data required to respond in a timely manner to the threat of a major incident. Both data collection and analysis is often focused on events which have already happened, neglecting the potential for a new set of unforeseen circumstances to make a ‘different kind of accident’ happen. Confidential reporting, with its focus on potential accidents, can provide an alternative stream of information, helping to predict what is largely unpredictable by conventional analysis.
5. Safety defences are bolstered by confidential reporting A confidential discussion with a reporter about how they perceive safety on the ground can reveal an awful lot about the safety defences put in place by an organisation to ensure no-one ever gets injured. It is even possible to map these defences out in bow-tie analysis which shows the threats to the key safety defences, and the measures put in place to mitigate these. Reaching a shared understanding of what is actually in place through dialogue, and where the ‘chinks in the armour’ are, can benefit everyone who plays an active part in maintaining safe systems of work. By listening to the experience of frontline staff, more robust safety defences can be built, and in some cases strengthened.
6. Confidential reporting is a key driver of proactive safety culture A Danish professor called Erik Hollnagel has coined the phrases Safety-I and Safety-II. In Safety-I, the safety culture is reactive and focuses on human error and what is going wrong in an organisation. There is a sense in this kind of safety culture that you wait around until something happens, and only then do something about it. Safety-II, on the other hand, adopts a proactive stance, and is interested in learning from events before they become incidents or accidents. Confidential reporting is a key driver of Safety-II culture, because it encourages a proactive management response to a safety issue before blame enters the equation. It’s about looking at the safety issue, rather than the individual who may have made the report.
Example 1. One contractor was especially grateful to receive one of our reports on driver fatigue and long travel times. Their own investigation in fact reveal some exceedances, and concluded there was a need for more effective monitoring. More staff briefings were scheduled and corrective action was taken. IT investment for the more effective monitoring of travel times and working hours is now on the contractor’s agenda. Operational feedback from a CIRAS reporter played a critical role in the re-assessment of safety risk, and the drive for business improvement.
Example 2. A CIRAS report about disrupted safety critical radio communications at a major port led to a full investigation. There was only one radio channel available for each terminal, and the potential for communications to become confused, or misunderstood, was high. After the two freight operators using the port, and the port authority itself, agreed to add an additional radio channel, the safety risk was effectively eliminated. The CIRAS report triggered an investigation involving the collaboration of several different parties, and a robust action plan to tackle an obvious risk.
Example 3. CIRAS makes a difference on the infrastructure too. A long-standing AWS fault at a signal was repaired soon after it was reported to us. But Network Rail weren’t content to leave it there. They amended their procedures to help respond more quickly to faults of this nature in the future, modelling a strong safety culture which responds robustly to information from an independent source.