Learning from Incidents to Create Safer Workplaces: Part 1 – Barriers to Learning from Incidents

This is the first part of a two-part article. Click here to read the second part.


As Singapore begins to move beyond the COVID-19 pandemic in 2022, many businesses are resuming their regular operations and catching up with the progress of previously delayed projects.


At the same time, the nation has recorded a total of 20 workplace fatalities between 1st January 2022 and 6th May 2022. Among these cases, seven were of similar nature to those reported in 2021 – i.e., related to forklifts, falls from ladders and falls through fragile surfaces – and were caused by either inadequate or lack of basic safety and health control measures. Consequently, a 2-weeks nationwide 'safety time-out' was initiated on 9th May 2022, hoping that organisations can learn from past incidents and review their workplace safety and health (WSH) management systems [1].


An incident is an unexpected event that led to a negative outcome or could potentially have done so [2]. In order to learn effectively from past incidents to avert future incidents and create safer workplaces, organisations must identify the incidents, reflect on the incident, determine the lessons learned from the incidents and put those lessons into practice [3].


Regrettably, the workplace fatalities continued to rise and hit 36 cases by 1st September 2022, close to the 37 cases reported for the whole of 2021. As a result, the Ministry of Manpower had to introduce a series of new measures (e.g., a six-month “Heightened Safety” period) to compel organisations to enhance their management of WSH [4].



So, why is learning from safety incidents a seemingly challenging endeavour for organisations? Safety literature has revealed some symptoms and causes of failure to learn from incidents [5].


Symptoms and Causes of Failure to Learn from Incidents


1) Under-Reporting of Incidents


Voluntary incident reporting practices tend to experience under-reporting, resulting in missed learning opportunities and misguided confidence in the organisation’s safety management system.


For instance, research conducted in Sweden has revealed the reluctance of railway maintenance technicians to report incidents due to the experience of inappropriate or negative feedback from their employer, which led to a lack of trust. This issue was also engendered by their attempt to save ‘face’ for fear they may be shamed, blamed, and excluded by their co-workers [6].


Organisations can analyse under-reporting of incidents by enquiring workers on site to determine the latest occasion of injury and verify if the incident had been recorded in the database. Another approach is to investigate a significant incident at work, determine the likely precursor issues and question whether they have happened in the past year.


2) Poor Quality Reports


Some incident reports may comprise incomplete data (e.g., missing facts or ambiguous sequence of events) and/or biased information that attempts to position the incident reporter in a more positive light, thus, offering little insights for improving safety at work.


The possible causes of poor report quality include deficient data collection methods, lack of access to appropriate data collection tools and non-involvement of key stakeholders (e.g., witnesses) during the fact-finding process.


Organisations can diagnose poor-quality reports by engaging the parties involved in the incident for critical review to identify inaccuracies, biases and missing information.


3) Root Causes Not Identified


Some investigations may be restricted to identifying the direct causes of the incident (e.g., technical failure of equipment or inappropriate behaviour of workers) without specifying the underlying factors or root causes (e.g., inadequate maintenance budget leading to equipment corrosion or tolerance of inappropriate ‘shortcuts’ by supervisor).



This phenomenon may stem from the lack of training for the incident investigators, inadequate time for in-depth analysis, or the prejudices of managers who wish to downplay their responsibility in the incident.


Organisations should, therefore, assess the balance in recommendations between quick fixes (e.g., sending workers for training) and more long-term and in-depth changes (e.g., implementing fundamental safety principles or altering the system design).


4) Deficiency in External Learning


Many factors may obstruct the sharing of information on lessons learned between different sites of the same organisation and between different organisations within or outside the same industry. Indeed, history has shown that failure to learn from others’ incidents is a cause of some major disasters.


For example, the Fukushima nuclear incident could have been avoided if they had learned from the other US and European nuclear plants and implemented the safety device to prevent the build-up of hydrogen gas inside the reactor buildings.


This problem in learning from others may arise from the ‘this will not happen to us’ mindset as well as fears pertinent to the reputation of individuals, groups, and organisations.


One way to detect this issue is to inquire if changes have been made to the organisation’s operating procedures due to a recent incident at other sites or organisations.


5) Ineffective Follow-up on Corrective Actions


In some cases, recommendations made from incident investigations were either realised very slowly or not implemented at all. For instance, in another study on the Swedish railway sector, it was found that about 20% of recommendations made by the investigation board did not result in any corrective actions [7].


This issue could be caused by the reluctance to change, inadequate budget or time as management may be complacent with safety matters, or the absence of ownership and buy-in because external experts had proposed the recommendations without inputs from internal stakeholders.


In order to address ineffective follow-up, organisations can establish the investigators’ level of influence and determine if top management needs to take further actions.


To sum up, the first part of this article has illustrated several barriers to learning from past incidents and suggested some measures to mitigate the challenges. However, to foster effective learning from incidents to create safer workplaces, organisations should apply the framework proposed in the second part of this article.


Click here to read the second part of this article.


References


[1] Ministry of Manpower. (2022, May 8). Ministry of Manpower, Workplace Safety and Health Council, Industry Associations and NTUC make joint call for safety time-out at workplaces. https://www.mom.gov.sg/newsroom/press-releases/2022/0508-safety-time-out


[2] Murphy, V. L., Littlejohn, A., & Rienties, B. (2022). Learning from incidents: Applying the 3-P model of workplace learning. Journal of Workplace Learning, 34(3), 242-255.


[3] Drupsteen, L., & Guldenmund, F. W. (2014). What is learning? A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management, 22(2), 81-96.


[4] Ministry of Manpower. (2022, September 1). Heightened safety period measures to address spate of workplace fatalities. https://www.mom.gov.sg/newsroom/press-releases/2022/0109-heightened-safety-period-measures-to-address-spate-of-workplace-fatalities


[5] Dechy, N., Dien, Y., Drupsteen, L., Felicio, A., Cunha, C., Roed-Larsen, S., Marsden, E., Tulonen, T., Stoop, J., Stručić, M., Vetere Arellano, A. L., van der Vorm, J. K. J., & Benner, L. (2015). Barriers to learning from incidents and accidents. ESReDA.


[6] Sanne, J. M. (2008). Incident reporting or storytelling? Competing schemes in a safety-critical and hazardous work setting. Safety Science, 46(8), 1205-1222.


[7] Cedergren, A. (2013). Implementing recommendations from accident investigations: a case study of inter-organisational challenges. Accident Analysis & Prevention, 53, 133-141.