CHECKING FOR BIASES IN INCIDENT REPORTING. IN: ACCIDENT PRECURSOR ANALYSIS AND MANAGEMENT: REDUCING TECHNOLOGICAL RISK THROUGH DILIGENCE

After any technological disaster, there are questions and considerations about the precursors of the accident and whether or not the accident could have been prevented. This chapter on checking for biases in incident reporting, from a section on risk management, is from the proceedings of a workshop (Washington, DC, July 2003) sponsored by the National Academy of Engineering's (NAE) Accident Precursors Project. In this chapter, the authors address the vulnerabilities of voluntary reporting schemes in terms of the quality and quantity of incident reports. Motivated by observations made during reanalysis of voluntary reported incidents at a chemical process plant, the authors first briefly review the literature on the reasons why individuals fail to report incidents in general and then evaluate their relevance of this body of research for their study. The project then entailed a diary study in which plant operators were asked to report their recovers from self-made errors under strictly confidential conditions, outside of the normal near-miss reporting system (NMRS) for that plant. In addition to descriptions of recovery events, the authors asked the plant operators to indicate whether or not (and why) they would normally have reported the event. Reasons given were then categorized according to the taxonomy of possible reasons for nonreporting, devised by the authors. The authors discuss their results in terms of the reporting biases identified and the authors propose possible countermeasures to improve the existing reporting system. The results showed that most reasons given for not reporting an incident were because there were no remaining consequences from the incident or there were no learning opportunities to be had from the incident. However, this "all's well that ends well" approach may not prove to be the most satisfactory in a climate of learning about accident precursors. Management has a sincere interest in learning about the personal and system factors that make successful recoveries possible; they must better communicate this interest to their plant managers. The authors note that the fact that none of the participants mentioned being afraid or ashamed to report errors may be a very positive indicator of the plant's safety culture.