Attending by trending

It can be seen in the previous Section that there is a difference between reporting a good experience and a bad experience such that the latter one involves more in-depth review and analysis of something that went bad. Something going bad, i.e. the ‘incident’, initiates the question ‘why it went bad’ and inherently means that there were adverse underlying reasons to make it go bad.

No matter how successful a programme is, or has been, due to the human nature and physical unknowns, there is always a potential for an act or condition that may result in incidents and majority of these acts and conditions do not happen randomly. The underlying reasons to create that act or condition (i.e. errors/mistakes) can be traced to long standing issues that have gone unnoticed  primarily owing to a process failure that needs to be identified and corrected/improved.

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This fact that errors will occur needs to be accepted by the management and personnel, but it is essential to acknowledge that remediation and reaction to the errors are more important than the errors themselves. As rightly stated by James Reason:

“The most detrimental error is failing to learn from an error” [53].

In that manner, it needs to be understood by everyone at site (or plant/project) organisation that it is more important that the errors/mistake/failures are not repeated and, if repetition inevitably happens, the reactions to the next occurrence is improved and consequences are minimised and/or mitigated. Committed errors ought to be acknowledged less as a matter of concern than as a source of learning and experience from which the owner/operating organisation and the industry can benefit. This acknowledgment is essential due to the facts about failures that:

— They are lessons learned that indicate that some elements of the programme are not working well and in need of improvement in order to prevent recurrence of an FMI event in case of a failure, or escalation into an FMI event in case of a near-miss/close-call;

— When let go unreported and/or unevaluated, a potential sequence will be the recurrence of errors and, very likely, with more serious consequences to the plant/site/station equipment and personnel;

— They are the proof of vigilance, anticipation and questioning attitude which are the positive traits of staff.

Therefore, collection, trending and analyses of bad experiences, i.e. ‘incidents’, as well as collected expert and leader perceptions, opinions and judgments on an incident, lead to the identifications of specific areas where the gaps lay and to those areas for improvement. In addition to reporting, incidents need to be analysed and trended for continuous improvement of FMMP and associated processes, procedures and practices. The extent of analysis depends on the complexity and severity of an incident, and hence recording and trending need to identify the type of incident. Regardless, any classification and trending need to encompass all the incidents that could be a learning opportunity.

Generally, all acts or conditions (failures) result in actual, potential or avoided consequences.

Accordingly, FMI incidents may be defined and classified in the following manner:

— Event (failure with harm): FM related incidents that occur due to an act or condition and cause harm to safety or performance,

— Near miss (failure with ‘dodged’ harm): FM related incidents that occur (or would occur) due to an act or condition, but do not cause harm to safety and performance under the time or situation (e.g. owing to unintended or coincidental defences, prompt recovery/mitigation measures or luck); however, they could have occurred, caused harm, in different circumstances,

— Close call (failure with an ‘averted’ harm): FM related incidents that could have occurred or led to a harm; but their occurrence or consequence was avoided by timely observation, interpretation or intervention.

It should be noted that, there is no ‘one size fits all’ classification and there are various definitions for incidents. For example, near misses and close calls are sometimes used interchangeably (or they are treated as the same) since they both ‘dodged a bullet’ in a situation

or circumstance, while in some literature, such as Ref. [54], close call has a distinctive definition, as:

“Any unsafe act (formerly termed irregular working) or unsafe condition that in different circumstances could have led to an accident or personal injury or could have resulted in damage to property or equipment. These are occasions where no one was hurt or nothing was damaged, but this is more by chance than by the application of systemic controls” [54].

Also, a widely used method to trend the events by FMMPs in the industry, have two classifications for ‘event’, based on the severity of consequences: major (or high level) event and minor (or low level) event. In such classification, a ‘major event’ is defined as a consequential incident that brings the tasks to a halt, reported and evaluated, while a ‘minor event’ is a non-consequential incident where the adverse condition is a ‘correct as you go’

condition. A minor event is reported and disseminated only to increase information and knowledge for FMM and to provide additional data for measuring the health of the FMMP, the organisational culture and plant practices.

For the purpose of this publication, definitions based on acts and conditions that have actual, potential and avoided consequences, and accordingly classifying the FMI incidents as events, near misses and close calls, is particularly useful for two reasons:

— Separately classifying near misses and close calls distinguishes the way one learns from them: reactively or proactively, i.e. realising the hazard and harm after or before the incident, respectively (or, in simple terms, the difference between ‘being lucky’ and

‘being vigilant’);

— From OPEX, it can be seen that most FMI events could be predicted from previous near misses and close calls in the same or other organisations with similar programmes.

Again, there is no perfect classification system; however, whatever the classification is, the underlying objective is always to learn from incidents and the learning starts with reporting, classifying, analysing and trending them. Accordingly, there is no difference between incidents, whether they are events, near misses and close calls, in terms of reporting them and learning from them to improve the programme, processes and procedures in the next round of Deming’s PDCA cycle.

Overall, a successful FMMP and its continuous improvement heavily relies on all employees and industry peers to be encouraged to record, report and communicate all FM events, near misses and close calls, inclusive of observation of minor conditions. Furthermore, it is essential for the improvement of a FMMP to ensure that all FMI events, near-misses and close calls (internal or external to the organisation) are reported and tracked. Accordingly, some good practices for reporting and trending culture are:

— Near-misses and close calls are treated just like events and all failures are reported regardless of their significance;

— Clear requirements and criteria for reporting of issues on FM generation, transport, potential for intrusion are in place and those are communicated to workers as part of the training programme and/or by other management system tools, such as job briefings, observation programme, condition reporting procedures;

— Events, near misses and close calls are documented in the CAP and their causes are evaluated in a graded approach;

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— Remedial actions in response to the findings from an incident are timely fed back and incorporated into the programme;

— Vigilance, anticipation and questioning attitude for potential hazards and events are never relaxed, guards are never let down and that complacency is not acceptable;

— Reporting of occurrence and acknowledgment of errors and precursors perceived as positive attitude and trait;

— Personnel reports, evaluates and takes corrective action with honest self-assessment and avoid the attitude that corrective actions (and the FMMP as whole) are ‘good enough’;

— Observation of challenges, potential hazards, error precursors are fixed, their discovery is recorded and tracked as a potential near-miss;

— Keeping a record of deviations, i.e. ‘tagging deviations’, in FMMP, processes, procedures, practices and cultural traits that makes following and understanding trends easier and also makes it easier to seek out and find trends of interest (here, it is essential to have the deviation screening groups to have good knowledge about deviations related to FM such that they would be able to address corrective actions to the right organisational departments).