In a recent article, Matthew Syed, author of “Black box thinking”, suggests that the NHS could transform its ability to save lives by adopting some of the incident management practices used by the aviation industry.
But equally the Financial Services market might also benefit from adopting these principles in their management of risk.
In recent years we have witnessed a whole succession of scandals that have resulted in catastrophic financially and reputational damage to the companies involved. Could these have been prevented if the organisations had had a better way of sensing what was happening through better use of incidents and near misses information?
Although accidents always make the headlines, statistically, talking a flight is one of the safest forms of travel; in 2015 there were only four fatal crashes from a total of 37.6 million flights. How did a seemingly perilous style of transport become so safe?
If two planes are involved in a near-miss situation, either on the ground or in the air the pilots are obliged to submit a report on the incident.
This data is consolidated and analysed from across the industry to understand why it happened so that it can be prevented in the future. An example from Matthew Syed is taken from a crash that happened in 1978.
“In 1978, for example, a plane crashed in suburban Portland, Oregon, after the pilot had become focused on a malfunctioning light bulb, but lost focus on dwindling fuel reserves, which ultimately caused the accident. On the surface, it looked like human error, but the black box investigation found uncanny similarities with other accidents.
It turned out that this was not a problem with the specific pilot, but with the limits of human perception.
New protocols were immediately introduced that addressed this problem. These were designed to create a more structured division of responsibilities amongst the crew so that they could not become fixated on the wrong problem, and to improve communication.” As a consequence, accidents caused in this way were eliminated overnight.
The reason that this process works in the airline industry is that airline professionals are willing participants in the reporting process as they know the focus is on finding solutions rather than scapegoats, unless negligence or malevolence is proven.
Learn the lesson for Risk Management
First, employees have to feel comfortable about reporting incidents and near misses without fear of blame; safe in the notion that these events are accepted as being inherent failings in the process.
Second, the business has to see the value of learning from incidents, which might require a change in culture and the adoption of easy to use tools for reporting incidents and near misses.
Third, modern risk management tools that incorporate intuitive web style screens enable the front line to easily participate and the second line to use analysis tools to understand the root causes.
Matthew Syed is the author of Black Box Thinking: The Surprising Truth About Success