Words: Bridget Leathley
There are some clues: accidents and dangerous occurrences are examples of reportable incidents, but there will be other incidents that are not notifiable or reportable.
RIDDOR creates further confusion as to whether the incident is the outcome or the cause of the reportable event, referring to incidents “which result in” or “cause” other events, which in turn could have led to accidents. For example, “an incident which causes the loss of stability of a floating installation” implies the incident is not the loss of stability, but the event (such as the weather) that caused it. Does this make carrying an open cup of coffee down a corridor an incident, since it could lead to a spill which in turn might result in a slip? Most organisations would probably regard this as an incident only if there was a spill.
The Health and Safety at Work Act does not use the word incident, referring in s 14 to its scope as including “any accident, occurrence, situation or other matter whatsoever”. But the Civil Aviation (Investigation of Air Accidents and Incidents) Regulations define an incident as “an occurrence, other than an accident, associated with the operation of an aircraft which affects or would affect the safety of operation”. In RIDDOR, incident includes accident but in the aviation regulations accidents and incidents are different.
When the Health and Safety Executive’s guide INDG 453, Reporting Accidents and Incidents at Work, was updated in 2013, the previous definition of an accident was updated to “a separate, identifiable, unintended incident that causes physical injury” but “incident” remains undefined.
The National Health Service (bit.ly/2ciuKHu) refers to a patient safety incident as “any unintended or unexpected incident which could have or did lead to harm for one or more patients”. This makes it clear that an incident includes accidents or deliberate acts that led to harm, as well as those “caught” before harm occurred.
Other organisations that want to adapt this definition should classify the nature of harm according to their risk appetite, and can include or exclude harm to property, process, product, image or environment, alongside harm to people. Each incident can then be considered as either an accident, which on this occasion did result in harm, or a near-miss, which on this occasion did not result in harm.
Instead of ‘any incidents’, staff can be asked to report those that would increase or reduce the risk of harm for a specific task, location or role
We will discuss more about near-misses and equivalent terms when we reach N in the lexicon. Perhaps the problem is that the word “incident” is too broad to be useful. The term “critical incident” might help organisations to focus on those that matter.
Critical incident technique grew out of psychological research by the US Army Air Forces during the Second World War. It was described in the Psychological Bulletin in 1954 (bit.ly/2cGK8Oy) by John C Flanagan as a means of “collecting direct observations of human behaviour in such a way as to facilitate their potential usefulness in solving practical problems”. The scope of Flanagan’s work was broad, including selection and productivity, but his approach can be used to collect safety-related observations. Two of the keys to its success are the clear definition of a goal, and actively seeking both negative and positive incidents.
Flanagan gave an example of collecting detailed information about pilots who had experienced vertigo or disorientation and survived to guide the redesign of aircraft cockpits. Instead of “any incidents”, staff can be asked to report those that would increase or reduce the risk of harm for a specific task, location or role. If the meeting rooms are going to be refurbished, ask about positive and negative experiences. The apparently trivial and unmanageable “I keep hitting my thigh on the corner of the table in meeting room 1 but this never happens in meeting room 2” is relevant to the redesign and purchase of new furniture.
If incidents fit into the recordable or reportable requirements of RIDDOR, we have no choice but to report them. Organisations must decide how to make voluntary reporting a useful and effective process by defining clearly what “incidents” they want to be reported. Though the process must not discourage the reporting of incidents that reveal unsuspected hazards, a focus on those critical to known risks in the organisation – perhaps selecting a new hazard each quarter – might produce a richer picture of what can practicably be done to improve safety and protect health.