Dr Mark Noort spoke to CIRAS members about safety voice and safety silence. Safety voice is about more than speaking up. See what Mark had to say – and what it might mean for you.

Poor safety reporting can contribute to harm, according to research by Dr Mark Noort from Leiden University in the Netherlands, who spoke about safety voice at CIRAS' 25th anniversary lecture on 17 September 2021. But why? What causes people to stay silent? And perhaps most importantly, what can we do about it?  

Safety reporting is a vital part of safety management. It ensures a vital flow of safety information. It can trigger managers to re-evaluate a situation. It can stop the momentum of hazards towards accidents. It’s also a financial obligation – with research showing it can cost organisations $13k[1] each time an issue isn’t reported.

Tragically, there are plenty of examples of accidents where hazards were known but people did not come forward to report them. Or worse, they did – but weren’t listened to. Deepwater Horizon. The Challenger space shuttle. The Al Ayyat train disaster, in Egypt in 2002, when a fire in the back of the train wasn’t reported to the train driver.

Mark defines ‘safety voice' as the extent to which people raise safety concerns – often to their superiors, typically beyond their job remit and based on a perceived risk. Safety silence, on the other hand, is when people withhold their concerns.

Surely most people do speak up? Mark’s research found that, even where there is the potential for fatal consequences, one in two people withhold their concerns. We asked our audience and, of 69 attendees, almost half felt that 50% or less of their people would report safety issues.

Why are people staying silent?

Mark’s literature review of 48 studies and 50 articles in 2017 found a huge range of predictors of safety silence behaviour, including leadership, fear, and workload. Mark also undertook 14 experimental studies and a review of black box material from 172 aviation accidents. His research identified 32 inhibitors of safety reporting.

Experimental research: walking the plank

Mark created a hazardous situation by setting up a plank between two chairs, which was described as incapable of holding the weight of an individual (even though in practice it was – for safety reasons!). In each experiment, Mark provided a volunteer with information to enable them to establish this, and then one of his researchers made as if to walk across the plank. Mark then observed the volunteer’s behaviour.

He found that for the 66% of volunteers that were concerned about the situation being unsafe, people either raised no concern because they felt no responsibility, were not aware of the issue, or were afraid to speak up. Some provided clues to their concern but fell short of actively expressing it. Their speech was nuanced, but still indicated concern. For example instead of saying ‘I think that is unsafe’ they might say ‘are you really going to walk over that?’. Their language held early indications of safety info, just to a lesser degree.

The black boxes

This study looked at what people said before a major incident. Only in 5% of the recordings did people fail to raise any safety issues – what varied was how much and how often. Mark found that, as accidents progressed, those involved spoke up less and less, especially where there was evidence they were not being listened to. This was even more marked in airlines from countries with strong hierarchical cultures – suggesting strict hierarchies can reduce listening. Conversely, where people got feedback to acknowledge their input, they spoke up more.

What could Mark’s research mean for you?

Mark concluded that it’s important to focus interventions on those things that will improve safety voice. Members often tell us that they have done this by putting reporting channels in place. The message is that this isn’t enough. It’s a ‘hygiene factor’ – their absence will stop people speaking up – but having them isn’t enough.

So how can you use Mark’s research to help improve safety voice in your organisation? Ask yourself three questions.

1. Are your people concerned enough about health and safety hazards?

If not, how do you make them more interested? Mark suggests making sure you know what the most common hazards are in your business. Raise awareness of these internally, and remind people that it’s important to report all concerns – big or small. Conduct hazard training to build people’s capacity to recognise hazards. Investing in behavioural safety culture can also help tackle complacency and enable people to recognise their personal and ethical responsibility for speaking up.

Mark also urged leaders to ‘be present’ – it’s a powerful signal that health and safety is a priority. On our travels, some of our members tell us that their leaders and senior managers are committed to doing safety tours, getting among frontline staff, on their turf, and talking to them about safety. That’s being present.

2. Are your leaders listening?  Really listening?

Getting out there is also a good way to get leaders to really listen. The oft-mentioned ‘open door policy’ means people still need to find the courage and motivation to walk through the door. It can give the illusion of being present while still acting as a barrier. There’s nothing like being among your people to hear the safety signals in that nuanced speech Mark discovered in his research. Barriers to reporting concerns formally are higher than chatting about issues informally.

Actively listening – and being seen to do so – will also help break down one of the most formidable barriers to safety voice: a belief that concerns will not be taken seriously. Training senior leaders in safety listening and making it part of what they do will reap dividends. Providing reporting channels that capture safety discussions as well as formal concerns can help capture more nuanced safety signals. Making safety concerns a standard feature on company meeting agendas can also help embed safety reporting as business as usual.

3. Are you closing the loop?

Of course, listening is only the start. We cannot assume that reporting concerns readily prevents harm. People also want to see action – whether that’s measures to fix a problem, or communication to inform or reassure staff about health and safety controls. Mark talked about ‘closed loop’ feedback – when the receiver of a message verified it with the sender. This can deliver enormous benefits.  It demonstrates you are listening and taking them seriously. It also ensures you’ve got the message right, and act effectively. And, of course, telling people what you’ve done because they raised their concerns shows them it was worth it.

What about confidential reporting?

The key thing about confidentiality is that it largely removes fear of consequences, such as losing a job, or stigma from colleagues or management. But it also enables communication. Even the availability of a confidential route sends a strong signal that the company wants to listen and recognises that it’s the concern and not the person's identity that matters most.

In conclusion

Mark’s message is clear. If you think that having safety reporting channels in place means you have all bases covered, you might want to think again. The good news is that many of our members are already doing great things to build a listening culture and break down barriers to safety voice. There’s a lot we can learn from each other, and CIRAS can help you listen.

Watch Mark’s lecture, plus view his slides (including full references for his research)

Read Mark's doctoral thesis on safety voice (PDF) or contact him at m.c.noort@law.leidenuniv.nl.

[1] Novak A, 2019. Improving safety through speaking up: An ethical and financial imperative. American Society for Healthcare Risk Management Volume 39 No.1

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