When organisations celebrate accident-free periods, I’m pleased for them but also curious – are they focusing on the many incidents that have the potential for serious harm? Every organisation experiences them and they happen more frequently than many realise.
As Andrew Hale noted in his 2002 research paper ‘Conditions of occurrence of major and minor incidents: urban myths, deviations and accident scenarios’, studies of major accidents have found that high potential incidents are often preceded by precursor events.
Organisations that focus on the potential within an incident rather than the actual outcome can get a fresh perspective on managing safety. For those operating in high-risk sectors, prioritising high potential events or incidents can significantly improve performance. Learning from the potential of incidents provides organisations with a good indicator of their inherent risk and shifts the focus from low consequence injuries to understanding major injury risk. So what can we learn from such an approach and what are the considerations when applying a high potential incident strategy?
One of the reasons why high potential events don’t tend to be commonly adopted is that, unlike lagging indicators, no standardised definition exists. The most common definition is an event that, under different circumstances, might easily have resulted in a fatality. In other words, if one factor had been different, someone would have died as a result of this incident. Some organisations, however, apply a lower threshold and include potential incidents that could have resulted in life-changing injuries.
External reporting is also patchy and organisations that do disclose how they manage high potential incidents use different methodologies so it is harder to make comparisons. This may however change with the inclusion of high potential incidents in the updated GRI 403: Occupational Health and Safety 2018, the reporting criteria for corporate sustainability.
A prerequisite for any organisation that wants to learn from its high potential incidents is to establish a method to identify them. Given that most do not result in harm, a good starting point is exploring the near miss, observations and safety reporting systems to identify the incidents that, in slightly different circumstances, could have resulted in very different outcomes. There are a number of methodologies which are used to identify the potential harm of an incident. Some involve an informal judgement, while others use formalised methodologies, including a risk matrix, severity scales, decision trees and algorithms. Whatever methodology is used, it is good practice to agree on measurement values so that everyone involved in conducting the reviews reaches similar conclusions.
A mature organisational culture means employees trust the process and believe that reporting will be welcomed
Not all incidents are equal in outcome, and some have greater potential for learning and improvement. In a world of finite resources, it’s important to prioritise incidents so that investigations are proportionate to the potential, not solely the actual outcome. The ‘scale and scope’ of a high potential incident should be greater and have more resources dedicated to it than a minor lost-time incident. A risk-based approach to investigations, categorising them by potential consequences, is the most common method to ensure resources are proportionately applied.
Although employees who experience high potential incidents while at work will identify many of these events, they will also arise when assets fail. Incidents often lie dormant until identified through inspections or failures. Establishing a strong link between the inspection regimes of safety-critical assets and processes, and the incident reporting system is essential. High-risk organisations also experience them in their operations, as will providers of safety-critical services and products. OSH professionals will find that establishing a common methodology for reporting all high potential events can be advantageous and will provide an invaluable metric for the organisational-wide management of risk (see the ‘HiPo incident’ diagram below).
The importance of organisational culture is often underplayed in high potential incident strategies. Given that many high-risk events will only be apparent to those performing the work, dedicated programmes focusing on these incidents tend to be bottom-up and rely on the participation of frontline personnel to share their experiences. This requires a system that encourages open and accurate reporting without fear of any recriminations. Training and communication will help to establish the necessary trust, providing a forum to discuss concerns around reporting and explaining why detailed investigations are being undertaken into incidents where nobody was hurt.
Training will also deal with a common factor associated with these incidents – risk normalisation. This describes the process in which individuals gradually become accustomed to high-risk situations and no longer recognise the dangers. Workplace transportation provides a good example. Often individuals don’t recognise the dangers of interacting near moving vehicles because their risk perception depreciates, and yet it remains the second highest cause of occupational fatalities.
OSH practitioners who are new to high potential incident reporting should be aware of how the information gleaned from reporting them will be received by leadership teams – and prepare the ground. This is important because how managers respond to mistakes, lapses and deviations that investigations reveal will shape the culture and determine workers’ future engagement. If OSH reporting has been historically focused on low consequence injuries and reducing rates of accidents, managers may be under the impression that all is well and good. They may feel they have sound control over risk. It’s not unusual for managers to be surprised and even fearful when introducing high potential incident reporting, because they realise how close the organisation has come to major incidents on a regular basis. Organisational factors, such as workplace set-up, scheduling and task planning often underlie many of these incidents. Management needs to be ready to acknowledge this and respond accordingly.
These challenges are worth acting on, however, because high potential incidents help leaders maintain ‘chronic unease’ and appreciate the fallibility of their current controls. Emphasising the importance of focusing on high potential incidents throughout the organisation also helps challenge the myth that serious accidents are freak events and reinforces the importance of critical safety controls.
When organisations improve their reporting and understanding of these incidents they often find that most of the serious incidents involve a small number of high-risk activities.
At Lloyd’s Register, for example, four activities account for more than 70% of all its high potential incidents: driving, working over water, confined space entry and work at height. In-depth studies of these four activities will often reveal a Pareto distribution whereby three-to-four precursors account for 80% of the incidents. There are various definitions of precursors. My preference is “a high-risk situation in which controls are either absent, ineffective or not complied with, and would result in a serious or fatal injury if allowed to continue”. Studies of confined space-related high potential incidents provide a good example of this, with five factors contributing to a significant number of incidents (see box below).
This level of analysis is invaluable. It can engage frontline workers and reveal the gaps between the procedure and practice, while also targeting supervision, training and monitoring activities. Precursor analysis also enables more. This is particularly important when changes in organisational factors such as scheduling and technology need to be made.
Five factors contributing to a significant number of confined space incidents
- Inadequate testing of the atmosphere
- Inadequate ventilation of the space
- Inadequate isolation of hazards
- Inadequate supervision
- Inadequate rescue plan
The term ‘one barrier from a catastrophe’ is often used in connection with high potential incidents and succinctly describes those that could have been much worse but for one factor. This single factor is often luck, such as an individual’s actions or location, an item of equipment, the time of day or even the weather.
Investigations into high potential incidents often identify the fallibility of controls for high risks, many of which are reliant on controls at the bottom of the hierarchy, or single barriers that represent a single point of failure. Corrective action provides the opportunity to combat this by establishing more effective controls. The following tests provide a healthy challenge to any corrective action:
- Proportionality: is the corrective action proportionate to the risk and does it improve control by removing, replacing or isolating the hazard? Behavioural controls, such as re-training do little to prevent reoccurrence, while procedural controls may add complexity and potentially increase the risk of a repeat incident.
- Singularity: does the change improve the overall strength of the system by resolving single points of failure and add additional layers of defence? This could involve introducing additional measures to prevent or detect variance, or recovery barriers that increase the capacity to fail safely.
- Fallibility: when we accept that human error will occur and recognise that control measures are never 100% effective and will deteriorate, our perception on the assurance process changes. Accepting the fallibility of controls helps challenge the assumptions we make when developing corrective actions.
Many organisations establish incident review panels to peer review investigations and review the strength and appropriateness of the corrective actions.
As behaviour-based safety pioneer Dominic Cooper notes, focusing on high potential incidents requires organisations to change their focus from a reactive view of responding to incidents, towards a proactive examination of the conditions that lead to major accidents. It also requires organisations to reassess what they view as success and focus on how effective their controls are. A mature organisational culture means employees trust the process and believe that reporting will be welcomed. Organisations that can navigate these challenges will, however, ensure that their efforts are focused on reducing their significant risks, and that must be the primary obligation of every OSH practitioner.
For further reading on the subject of high potential incidents and significant injuries at the workplace download the recent whitepaper from Lloyd’s Register. The whitepaper includes insights and knowledge sharing from industry experts.