[SystemSafety] Comparison of Confidential vs Non-Confidential Reporting Systems

[Olwen Morgan]

There are certainly problems in the area of safety reporting outside 
aviation. On both occasions when I have reported things to a regulator, 
I have faced sanctions from the client/employer. One client refused to 
pay a month's consulting fees and one firm fired me (although I had 
already decided to leave and deliberately provoked them into firing me 
so I'd get pay in lieu of notice). One of my colleagues, however, was 
absolutely petrified of losing his job even though he could see the 
problems.

The whole area is thicket of dysfunction. I can see ways in which 
cognitive biases contribute to problems but IMO this doesn't get 
anywhere near capturing the scale of the phenomenon. What one sees IMO 
is a complex interaction of (among other things):

- cognitive biases,

- problems of working culture,

- poor staff selection and training,

- inadequate protection for whistleblowers,

- perverse economic and institutional incentives for corner-cutters,

- spineless regulators that are just as clueless as the clowns that they 
are supposed to regulate,

- plain old-fashioned ignorance.

The only bright note that came my way recently was at a UK subsidiary of 
a large US corporate group. I worked for them on an agency contract and 
at the interview told them that I had been fired from my previous 
project for blowing the whistle. Fortunately, that particular company 
has a very strong corporate ethics culture and I have some reason to 
believe that being open about whistle-blowing may have helped to get me 
the contract.

Nevertheless, and to be perfectly honest, I'm glad that in 
semi-retirement I'm gradually exfiltrating myself from the morass.


regards,

olwen


On 17/10/2018 13:59, Gareth Lock wrote:
> Hi Mike,
>
> Aviation and confidential reporting works because there is a culture 
> that says reporting is good. It comes partly from the protection which 
> is afforded to crews for reporting. The FAA will reduce (remove) the 
> punitive sanctions if an ASRS report is made. The majority of 
> countries provide a level of legislative protection for evidence 
> entered via a reporting system, CVR or FDR.
>
> Healthcare doesn’t have that. However, this report shows that you can 
> change practices and reduce litigation if you change behaviours 
> towards reporting. 
> https://news.aamc.org/patient-care/article/best-response-medical-errors-transparency/ 
> (link out to a paper from there.)
>
> In high-risk industries, bonuses are paid when the lost time 
> incident/fatality rates are low/zero. If a report comes in, then the 
> team lose their bonus. So it is ‘easier’ to hide the reports than 
> learn from them.
>
> In addition to the reporting system, you have to have a Just Culture 
> to show it is ok to make a mistake, you have to have a learning 
> culture which means you look for others’ mistakes so you can improve 
> your own performance and you have to have a culture which provides 
> feedback to those who have reported to say what (if any) change can or 
> will happen. Reporting needs to be thought of as a system issue and 
> not just a platform for submitting things.
>
> Regards
>
>
> Gareth Lock
> Director
>
> M: +44 7966 483832
> E: gareth at humaninthesystem.co.uk
> W: http://www.humaninthesystem.co.uk
> T: @HumaninSystem
>
> Skype: gloc_1002
> WhatsApp: +44 7966 483832
>
> International speaker on human factors and non-technical skills
> Award-winning programme for Innovation in Diving (TekDiveUSA 18) - 
> http://www.thehumandiver.com/p/microclass
> Published specialist on non-technical skills - 
> http://www.thehumandiver.com/blog/sticky-published-articles
>
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> On 17 Oct 2018, at 13:49, Mike Rothon wrote:
>
>> I am looking for some recommended reading on the respective merits of 
>> confidential and non-confidential (open?) reporting systems with 
>> respect to 'safety events'.
>>
>> Aviation is one sector that has generally embraced the confidential 
>> reporting approach, whilst anecdotally I hear that it isn't (yet) 
>> used so widely in the medical sector.
>>
>> In general, I am trying to understand why it is considered to be 
>> beneficial for aviation, but not necessarily elsewhere.
>>
>> For example, is it just a natural human desire to know 'who done it' 
>> [sic] that prevents wider adoption, or does the fear of being named 
>> and shamed encourage people to behave more 'safety consciously'?
>>
>> I have made the usual Google search, but with surprisingly few results.
>>
>> Thanks.......................Mike
>> _______________________________________________
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>> systemsafety at TechFak.Uni-Bielefeld.DE
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