By Alice Turnbull, Director – Exploration and Development Environment, NOPSEMA and Jodi Goodall, Head of Organisational Reliability, Brady Heywood
Are there warning signs that your industry, or part of it, might be getting close to a major accident or serious harm event? How might a regulator see those warning signs and use them to analyse options and to act early, before a bad outcome?
Every major accident or business crisis is preceded by a series of smaller events or near-misses. The challenge lies in recognising and describing these indicators in a compelling way that triggers action.
Major accidents and other serious harm events are often complex – made up of many factors that come together on the day to cause a bad outcome. While it is difficult to predict the precise combination of those factors, we can often see the weaknesses in the system by looking at similar near miss events. Near misses precede every major disaster – often in patterns. These are early warning signs of failure.
These issues were the subject of a recent presentation and workshop by Jodi Goodall, Head of Organisational Reliability of Brady Heywood. The event was facilitated by NOPSEMA’s Director Alice Turnbull, at their Perth offices in September. The presentation was also viewed by 250 online participants from Australia and New Zealand Regulators.
Clarity of your big risks and controls
While serious harm looks different in every industry, the types of events are often well known by both industry and the regulator. For example, if you asked your colleagues “what are the big events that we never want to happen in our industry”, they would list most of them quickly. Conversation would slip into past stories of failure…
Similarly, the control strategies to prevent these big events are also well known.
A risk-based regulator requires a deep understanding of its industry’s catastrophic risks. But they need more than this to be effective in seeing the early warning signs of failure. Regulators require deep clarity of how those risks are caused, how they are controlled and when the most important controls are not in place or effective.
Jodi explained the ‘Bowtie Risk Assessment Method’ as a great way to visualise each major accident scenario, its causes and the key controls at an industry level. She introduced ‘Control Performance Standards’ as a way to objectively clarify the required performance of the most important controls, making it clear for both industry and inspectors when the control is in place and effective. This process defines the purpose of the control, its scope, how it fails, and the level of performance that must be achieved for the control to be working effectively.
Further, having clarity of the big risks and the most important controls forms a foundational language and framework for regulators to collect valuable near miss reports from industry. Setting out the types of near misses that a regulator wants to receive is critical for the industry to know what is important. Often, industry struggles to see how relatively small events credibly add up to a real and present danger.
Looking deep into the system
Events that cause serious harm aren’t simply bad luck or human error. While it is easy to stop the explanation of an incident at the actions of frontline workers, or those closest to the failure, incidents occur because important controls fail or are ineffective.
Human error is almost never the only contributing factor, rather it is a great starting point for any investigation. The reasons for controls being ineffective often lie deeper in the system, well before the day of the event.
Interestingly, the same latent systemic issues within major accidents can be found in near miss events. Each near miss provides a clue, like pieces of a puzzle. The clues tell us of the controls that are failing or ineffective – and addressing these, is how we prevent major accidents and serious harm events.
Reporting – getting the gold
Once the challenge of deciding what near miss data to collect has been overcome, the next step is figuring out how to collect that data and ensure its quality is high enough to be useful.
This topic generated considerable discussion in the in-person workshop. Some regulators turn to alternative sources of information to obtain the data or intelligence they need, such as systematically or selectively monitoring social media. Others use secondary sources, such as insurance claims, to verify the data they collect through formal reporting channels.
Jodi highlighted the logistical barriers regulators face to receiving reports with quality information. She also addressed the challenge regulators face of determining when a high volume of incident reports reflects a strong reporting culture (rather than poor safety performance), versus when a low number of reports may indicate underreporting and a poor reporting culture, which could signify unknown risks and warrant greater regulatory scrutiny.
A balanced approach when acting on near-miss information
Not every incident requires regulatory action. It’s crucial to strike a balance between creating the psychological safety that encourages reporting (i.e., not shooting the messenger) and the need for regulators to monitor compliance and take proportionate action when non-compliance is observed. Public perception and political pressures can also complicate this balance, i.e. the need to be seen to be acting.
Jodi shared a best practice strategy to achieve this balance – Civil Aviation Safety Authority’s (CASA’s) Just Culture approach which includes documented policy on how incidents are to be actioned in a fair and just way.
The group discussed a range of other regulatory tools and approaches that can be used in response to near-misses, including education, and communication. For example, providing regulated entities—and, in some cases, the public—with comparative performance data can promote healthy competition and drive improvements.
Industry learning from storytelling
Perhaps more important than regulatory action, is using near-miss data to encourage regulated entities to make improvements. An effective way to do this is by promoting ‘risk imagination’ through storytelling. A graph or a number on its own is often hard to connect to real-world risks. Stories, however, help people imagine what could have happened (and very nearly did) and translate near-miss data into a meaningful context.
The best regulators weave the ‘controls that failed’ into the story as the key learning – they resist the urge to blame individuals.
Conclusion – Turning weak signals into strong prevention
The key to preventing major incidents lies in our ability to recognise and act on weak signals before they escalate.
Near-misses offer invaluable clues, but they are only useful if we have the frameworks to interpret them, the systems to report them, and the courage to take action. This framework is underpinned with deep understanding within the regulator, of the big risks and how they are controlled.
By fostering a strong industry reporting culture and using compelling data and storytelling, regulators and organisations can turn nearmiss data into the driving force to prevent major accidents and serious harm.