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29 One challenge of implementing an incident reporting system is gaining worker trust and confidence, as they are on the front line of incident occurrence. Concerns are expressed in the literature research as to whether employees, users, or the public will actually report themselves as committing safe or unsafe acts, or report other incidents that can be precursors to good safety practice, accidents, or violations. Both voluntary and mandatory incident reporting processes are affected by the self-report possibility if the system is not structured to address the concerns of those who submit reports. Hartsfield-Jackson Atlanta International Airport has a confidential reporting system in place (see Chapter 9). Two common reasons cited in the literature for why incidents are not reported are failure to understand the importance of reporting or the potential harm that could result by not reporting. But there are other barriers to the reporting of incidents and near misses. Bridges (2000) identified nine barriers to overcome when establishing an incident reporting program and grouped them into four topic areas: 1. Potential recriminations for reporting a. Fear of disciplinary action b. Fear of peer teasing c. Fear of an investigation involving the concern 2. Motivational issues a. Lack of incentive b. Management discouraging near-miss reports 3. Lack of management commitment a. Sporadic emphasis b. Management fear of liability 4. Individual confusion a. Confusion as to what constitutes a near miss b. Confusion as to how it should be reported ACRP Legal Research Digest 19: Legal Issues Related to Developing Safety Management Systems and Safety Risk Management at U.S. Airports (Bannard 2013) presents an overview of the legal issues associated with voluntary incident reporting, including discussions on confidentiality and just culture. In addressing the possibility of civil or criminal litigation, ACRP Legal Research Digest 19 confirms that an organization seeking to establish a just culture will only be able to protect reporters and those persons named in such reports to the extent permitted by applicable laws (Bannard 2013, p. 11). Because there is often a negative stigma attached to the word âincident,â attempts have been made by various organizations to convey a less negative connotation and to promote better C H A P T E R 5 Encouraging Incident Reporting
30 Airport Incident Reporting Practices reporting. Terms such as âhazard reporting,â or even âoperational experience feedback,â have been used. In one study, a hospital wanting to overcome the negative connotation of the term âincidentâ and to encourage the filing of reports, established its program as âCondition Report- ingâ (Volz et al. 2012). Using the phrase âCondition Reportingâ was perceived to provide a more favorable avenue for employees and others to make observations and reports that could reflect either a positive, neutral, or negative state. The hospitalâs condition reporting program has all the elements of a regular incident reporting program. The change in the word from âincidentâ to âconditionâ was shown in the study to have resulted in an increasingly open and healthy culture, a lower threshold for reporting conditions, and a decrease in higher severity events after one year of implementation (Volz et al. 2012, p. S100). Safety Culture The accurate reporting of incidents can be influenced by a number of factors. Two such factors are an organizationâs safety culture and the actions of supervisors who enforce reporting requirements. Reason (1997) presented several concepts on accident prevention and managing organizational risks. A prime concept espoused is that organizations need to create an overall safety culture. A safety culture is one in which data are collected and people are informed about the risks and hazards they may encounter; individuals are encouraged to (and do) report incidents that occur, for which there is no recrimination (with some exceptions); and employees learn and change in response to the incidents. These concepts were identified as an informed culture, a reporting culture, a just culture, and a learning culture. Collectively, they make up an organiza- tionâs overall safety culture. Reporting and just cultures are important for an incident reporting system to work properly. Mentioned previously, barriers exist to the proper reporting of incidents. The literature research indicates that organizations with a positive safety culture, and in particular a just and reporting culture, will experience a higher level of incident reports because individuals are less fearful of the outcomes and understand better the value of reporting incidents (Hohnen and Hasle 2011). One airport in the synthesis study experienced an increase in the number of reported incidents as a result of its training efforts. Its assessment was that individuals did not previously know what they were to report or how to report it. Upon completion of the training, the airport started to see an increase in the number of incident reports. A reporting culture is one in which an atmosphere of trust exists. People are encouraged, and even rewarded, for providing essential safety-related information. If the connection between a safety managerâs attitude and incident reporting is viewed as positive, then trust is established and incidents get reported. If not, then trust is affected, which can lead to fear of reprisal and reduced reporting incidents can occur. A just culture establishes that employees are still to be held accountable for reckless or deliberate actions, but they are not to be unduly punished for unintentional errors (Reason 1997). Macrae (2016) states that rather than assigning responsibility for causing failures, incident reporting should assign responsibility for improving systems. This key concept focuses on getting away from using incidents for punishment and moving people toward working to improve the organization and being rewarded for the effort. Illustrative of a reporting and just culture is a research study by Okuyama et al. (2010). Their study examined the relationship between nursesâ perceptions of incident reporting, the fre- quency of incident reporting on wards, and safety management in hospitals. They concluded that on hospital wards where staff and safety managers discuss incidents and their root causes,
Encouraging Incident Reporting 31 staff were less fearful of incident reporting, understood the significance of incident reporting, and reported incidents more willingly. Illustrative of a just culture is a study by Probst and Estrada (2010). They reported that under- reporting of accidents and incidents can be predicted both by perceptions of an organizationâs safety climate and the degree to which supervisors enforce safety policies. Their study concluded that when employees perceive their organizational safety climate to be positive, they engage in far more reporting than if it were perceived negatively. The authors further noted that when employees report having supervisors who enforce safety policies, they not only experienced far fewer accidents, but they also fully reported all of those accidents. On the other hand, among employees who perceived a poor safety climate and/or lax enforcement, the ratio of unreported to reported accidents was greater than 3:1 (Probst and Estrada 2010, p. 1443). In addition to reporting and just cultures as ingredients for a successful safety and incident management system, Reason (1997) also identified the need for informed and learning cultures. An informed culture is one in which leading and lagging indicators of safety performance are collected, analyzed, and disseminated. A learning culture infers that the airport organization reviews safety trends and incidents, changes processes and practices, and trains employees to improve their efficiency and effectiveness. The goal of an incident reporting system is to learn from the investigation and analyses of them. As Macrae (2016, p. 72) states, âRepeated reports of the same type of event suggest a strong culture of reporting but a poor culture of learning.â Incident Reporting Practices and Culture A 2011 report by the Transit Rail Advisory Committee for Safety has application to airports. In describing a safety culture, it states, âA safety culture is one that collects the right kind of information, analyzes and disseminates that information, learns from its mistakes, and treats its employees fairlyâ (Transit Rail Advisory Committee for Safety, 2011, p. 3). That is also a descrip- tion for an incident reporting program. The report describes how effective safety management systems use data-driven performance management practices and independent audits to drive continuous improvement of safety. It further describes effective practices as follows: ⢠Leading indicators of safety performance, safety culture, and accident precursors are defined, measured, and monitored. ⢠All employees understand the value of collecting and reporting data to support risk analysis, address unsafe conditions, and prevent accidents. ⢠Reliable data are collected on operational performance, safety, maintenance, near misses, and training. Systems are in place to analyze trends, track and report data, and guide decisions. Variations from expected outcomes are reviewed to understand where the organization is failing and what corrective action is necessary to restore performance. ⢠Performance measures based on industry standards are cascaded through the organization so everyone is clear about fulfilling strategic safety goals. The performance measures are used to continually encourage all levels of the organization to reduce the risk to the agency. ⢠The organization uses performance measures to evaluate the effects of new programs and processes on safety. ⢠A hazard analysis process is in place for identifying safety issues and concerns, including those associated with human factors and changes to operations or equipment. Data are analyzed to provide possible policy, process, or equipment modifications to eliminate or mitigate hazards. ⢠A reporting system is in place that allows employees to report important close calls/near misses and unsafe conditions to a neutral third party without retribution.
32 Airport Incident Reporting Practices ⢠Capabilities for swift learning, flexible role structures, and quick situational assessments are developed to mitigate risk impacts. ⢠A hierarchy of controls are identified and clearly understood. General characteristics and best practices of incident reporting systems culled from the literature search include the following key attributes: ⢠The organization supports and encourages a culture of hazard and incident reporting. ⢠Reporting is made easy and received from a broad range of sources. ⢠Individuals participate in the reporting process. ⢠The reporting system is non-punitive and protects the privacy of those who make reports. ⢠A structured process is in place for reviewing and investigating incidents, identifying root causes and the weaknesses in the system, and developing action plans. ⢠Feedback is provided to the person making the report, if the report is not anonymous. ⢠Investigative results are used to improve safety systems, hazard control, risk reduction, and lessons learned through training and continuous improvement. ⢠Information or summaries of investigations are disseminated in a timely manner as part of the feedback and culture process. Culture Survey The safety culture in the healthcare industry is often measured using the U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey. The AHRQ is the lead federal agency charged with improving the safety and quality of Americaâs healthcare system. By using a standardized survey, hospitals, medical offices, and/or other similar health unit organizations are able to better benchmark their capabilities among each other. The literature search found that there are quite a few culture surveys available on the web, but there did not appear to be a standard culture or climate survey developed solely for the airport industry. Airports Council International (ACI) has administered to its members a culture survey based on SMS principals, but that survey included aerodrome operators, airlines, and ground handlers worldwide (ICAO 2015). Among the surveyed airports, only four indicated they perform or assess organizational surveys on safety climate or culture [Question 5.h.]. Different Ways to Report Incidents The process for formal submission of reports on hazards and incidents varied among the airports [Question 3.e.]. The use of a telephone and website were most common, followed by e-mail and written and verbal notification [Question 3.f.]. Social media use and a suggestion box were available at half of the airports. Ten of the airports indicated on the survey that the general public is able to report acci- dents, incidents, hazards, or near-miss situations [Question 2.b.]. However, the methods and con venience of reporting by the general public varied. Interviews established that many of the airports allowed the general public to make a report through the web, but some websites were not easy to find or were not specifically for incident reporting but rather for general comments. Anonymous reporting was not the norm. The Sarasota Airport Authority allows for anonymous reporting through its courtesy phone and comment box (Figure 7). Hartsfield-Jackson Atlanta International Airport has a confidential reporting system in place (see Chapter 9). Having a prominent website button or physical indication of where and how to report a safety issue is considered a best practice.
Encouraging Incident Reporting 33 Figure 7. Two ways the Sarasota-Bradenton Airport facilitates public and employee reporting of incidents. Photo credit: Author.