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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence (2004)

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence

These are just two examples of organizational design perspectives on reporting schemes. Much less is known about the individual reporter’s perspective: (1) when and why is an individual inclined to submit a formal report of a work-related incident; and (2) what aspects of an incident is an individual able and willing to report.

The starting point for the investigation described in this paper was an observation made during a reanalysis of part (n = 50 reports) of a large database of voluntarily reported incidents at a chemical process plant in the Netherlands, where we encountered very few reports of self-made errors (Kanse et al., in press). This was surprising because this plant had been highly successful in establishing a reporting culture; minor damage, dangerous situations, and large numbers of near misses (i.e., initial errors and their subsequent successful recoveries) were freely reported, two reports per day on average from the entire plant. The 200 employees of the plant, as well as temporary contract workers, contributed to the plant’s near-miss reporting system (NMRS), which had been operational for about seven years by the time we performed the reanalysis. The NMRS was regarded as a “safe” system in terms of guaranteed freedom from punishment as a result of reporting an incident. Even more puzzling was that references to self-made errors were also absent in the particular subset we were analyzing—successfully recovered (initial) errors (human failures) and other failures, which were thus completely inconsequential. The question was why plant operators did not report successful recoveries from self-made errors.

To address this question, we began by reviewing the literature on the reasons individuals fail to report incidents in general and then evaluating their relevance for our study. We then generated a taxonomy of possible reasons for nonreporting. Next, we instituted a diary study in which plant operators were asked to report their recoveries from self-made errors under strictly confidential conditions, outside of the normal NMRS used at the plant. In addition to descriptions of recovery events, we asked them to indicate whether or not (and why) they would normally have reported the event. We then categorized the reasons according to our taxonomy. The results are discussed in terms of the reporting biases we identified and possible countermeasures to improve the existing reporting system.

REASONS FOR NOT REPORTING

We began our search with the Psychinfo and Ergonomics Abstracts databases to ensure that we covered both the domain of work and organizational psychology and the domain of ergonomics, human reliability, and safety. The key words we used were “reporting system and evaluation,” “reporting barriers,” “reporting tendencies,” “reporting behavior,” “reporting biases,” “incident report,” “near miss report,” and, in Psychinfo, simply “near miss.” We included truncated forms of the keywords (i.e., “report*” for report, reporting, and reports) and

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