By Robert Baron
On first mention, many of the managers and supervisors I speak with are supportive of the idea of an error reporting system (ERS) in their organization. The benefit of an ERS is fairly obvious; if errors are reported then fixes can be implemented and errors can be diminished, or in some cases even eliminated. This in turn creates a safer working environment as well as reduced vulnerability to litigation. Yet, in light of all these benefits, many organizations have failed to adopt and support a formal ERS.
Up until this point there has not been a regulatory requirement for an ERS. However, a paradigm shift has begun to occur with both the introduction of soon-to-be mandated FAA human factors (HF) training programs and safety management systems (SMS) in the United States. Both of these programs call for an ERS and suggestions for implementation are spelled out accordingly. On the HF side, one should reference the Operator’s Manual for Human Factors in Aviation Maintenance published by the FAA. On the SMS side, information can be found by accessing FAA Advisory Circular 120-92. But why the major push for ERS’s these days?
The well-known Heinrich Ratio states that, for every fatal accident, there will be three to five nonfatal accidents and 10 to 15 incidents; but there will also be hundreds of unreported occurrences. Unreported occurrences are extremely problematic since no defenses can be employed if nobody knows these occurrences exist. This makes sense.
However, the resistance encountered in employing an ERS generally stems from peoples’ natural propensity to deny they make mistakes in the first place, as well as their fear of retribution or punishment for disclosing such mistakes. This can create a “darned if you do, darned if you don’t” mindset. From a personal standpoint, employees may feel that error reporting has clear advantages, but embarrassment and potential punitive implications might far outweigh the advantages.
A good and effective safety culture must include an ERS. The key to a successful ERS is a just culture, one that acknowledges that well-intentioned people still make mistakes and should not be punished for slips, lapses, mistakes, and other common errors. Yet, a line is still drawn where willful violations and purposeful unsafe acts will be dealt with in punitive form.
The general indications are that only around 10 percent of actions contributing to bad events are judged as culpable (Reason, 2004, as cited in Global Aviation Information Network, 2004, p. vi). The bottom line of a just culture is trust. Employees must know that they can report errors without sanction. Once this trust is established, then an organization can have a reporting culture, something that provides the system with an accessible memory; this, in turn, is the essential underpinning to a learning culture (p. vi).
Similarly, G. Eiff (1999) suggests that, “An effective and systematic reporting system is the keystone to identifying the weakness and vulnerability of safety management before an accident occurs. The willingness and ability of an organization to proactively learn and adapt its operations based on incidents and near misses before an accident occurs is critical to improving safety.”
What steps to take
Are you ready to start your ERS? If so, there are a number of steps that you will need to take in order to get your basic ERS up and running.
First, you will need to announce that an ERS is going to be established within your organization. Upper-level buy-in is a must. In fact, those within the highest positions of the company should make it clear that the ERS is a non-punitive reporting system and that the system has the complete support of management.
Second, depending on the size of your organization, you may need to create an ERS department. This department can fit very nicely within the HF or SMS departments, if one or both of these exist. Larger organizations might want to create a dedicated position for the ERS but smaller organizations may do well by delegating the ERS functions to a safety manager or someone else in a safety position.