This is the first of two stories written by Dr Steve Fletcher, Director and Occupational Psychologist at the Occupational Psychology Centre (OPC), around Post Incident Investigations that share some different insights that managers may find useful when working with employees who have had safety of the line incidents.
For over 20 years, the OPC has undertaken many Post Incident Investigations with rail employees across a variety of roles – train drivers, conductors, signallers and track workers. Sometimes they are asked to work with an employee who has had a safety incident, not always because they had the incident, but because they didn’t report it.
For the benefit and safety performance of all concerned – from the employee, their team and through the organisation, we need employees to report incidents. It’s important to learn from them; to understand the human factors contributing to them, what happened and the outcomes needed to help ensure they don’t happen again. Employees also need to learn from an incident to help make sure they return to work safely and are better equipped to avoid another incident. Incidents need to be explored and investigations take place as close to the event as possible, so that the true nature of what may have occurred can be explored with insight and accuracy.
The OPC often hears real concerns from managers about those employees who are out on the job, working unsupervised, and who don’t report an incident – whether wholly or partially responsible for it. In their experience, some of the possible reasons why this may be are:
1) An employee may not realise they’ve had an incident
For example, a driver has a ‘fail to call’ at a station, but they may not have recognised this error. This may be picked up via control, the conductor or a customer complaint after the event. Alternatively, they may act on incorrect information such as a conductors’ ‘2 on the bell’ to the driver when the signal at the end of the platform is still red. The employee may not realise the error, or accept it was an incident afterwards. In most circumstances, this may be down to ‘operating in auto-pilot’ without full conscious control. They may have been distracted by another task or have thought-intrusion whilst being in autopilot. A post-incident investigation development action might be to help the employee with their non-technical skill (NTS) of concentration and checking.
2) The employee recognises the error, but consciously decides not to report it.
a) The employee may feel it was only a minor mistake. They may minimalise the error. For example, rationalising ‘I only over-ran the station by a couple of feet’. Maybe because there was no damage or injury as a result of the event, they choose not to report it. We need to help employees understand that all incidents are incidents, however small. The danger of minimalising the risk is that other more significant events may not be reported. Small mistakes can often be precursors for more serious safety incidents. Getting to the root cause of a safety incident, however small, is important for future safety performance.
b) The employee may have had a number of incidents. They may feel that another reported incident might cost them their job. By not reporting it they hope they won’t be found out. Some believe they will be reported by another employee e.g., a signaller or a station dispatcher and therefore absolve themselves of the responsibility for reporting it. Others are just unable to bring themselves to do it.
c) Some employees are exceptionally conscientious at work. Some employees strive to always get things right and hate getting things wrong. When these types of employees do have an incident, they may feel really bad and so try to move on from the incident as soon as possible without reporting it. One driver the OPC worked with made an unscheduled stop at a station; they realised the error promptly, then feeling so bad about it they drove their train away from the scene as quickly as possible. Days later, and after numerous sleepless nights, they eventually reported it to their Head of Drivers.
d) Some employees delay reporting which may look like a failed report. In some cases, employees may say that they didn’t want to cause a delay, and that they’ll report an incident later – with no intention of failing to report the incident at all.
The OPC recognises the importance of uncovering the underlying human factors into why an incident may occur. They aim to help organisations and employees get to the root cause(s) for the purpose of learning and to help improve future safety performance. It is also key to support employees with the right kind of post-incident interventions such as training or a personalised NTS development plan, to help minimise the possibility of a further incident.
Dr Steve Fletcher commented “We understand that it’s a very worrying and concerning time for any individual, team, manager or rail operator after any safety incident. Making mistakes is an inescapable fact of life. It is what we do at the point of the mistake and how we learn from it that makes it a success rather than a failure. Those employees who accept their mistakes, report them and want to learn from them are the ones who are more likely to avoid future safety incidents.”
Want to know more?
Join the company’s complimentary webinar exploring Post Incident Investigations, and how they can help to improve safety performance. Tuesday, 5th October 2021, from 9.30am to 10.15am. For more information, visit https://www.theopc.co.uk/contact/ or email firstname.lastname@example.org