Awareness of risk
RAIB investigations reveal that organisations rarely fully understand all the threats to safety and the associated risks. In many cases, the threats to safety have been identified, but the associated risk is not always well understood. However, from time to time, investigations reveal a threat that had not been identified.
One way to conceptualise threat/risk awareness is by adapting the Johari window and the concept of knowns and unknowns popularised by the former US Secretary of Defense, Donald Rumsfeld.
Every organisation will have a range of threats/risks that it believes it understands reasonably well because the threats (i.e. hazards) are obvious and the associated risk data well understood.
For these ‘known knowns’, the challenge is to ensure that the organisation’s understanding of the risk remains valid as circumstances change.
For other threats, the risk may be less well understood, in which case the challenge is to understand better the threat and/or the associated risk.
So, how does an organisation take account of the unknown unknowns? How do you detect something that’s hidden from you?
The simple answer is that you look for it. You look for clues and weak signals that something is awry. This could be an inconsistency in the data, something said to you in an everyday conversation, or something you notice when out and about on the network.
The instruments available to every rail industry leader monitoring their organisation’s safety performance should include:
■ Eyes and ears, watching and listening.
■ Conversation, with those that really know what is happening.
■ Engagement with local managers, supervisors and safety representatives.
■ An open, honest and just culture.
■ Smart data collection and analysis.
Hidden threats
RAIB’s investigations have identified a number of reasons why threats to safety remain hidden from leaders in railway organisations. These include:
■ Inadequate data: The railway industry is very good at collecting data on things that have already happened (i.e. lagging indicators). It is much less effective at collecting data that reveals how well its management systems are functioning and the extent to which they are effective in controlling risk (leading indicators).
■ Poor reporting: All railway organisations have processes to enable staff to report safety issues. The effectiveness of these is highly dependent on the safety culture of the organisation. The real measure of the effectiveness of any reporting system is the extent to which people feel that it is safe to report their own errors.
■ Lack of requisite imagination: ‘Requisite imagination’ has been described as the ‘fine art of anticipating what might go wrong’. Risk managers at any level of an organisation need to apply requisite imagination if they are to recognise threats not revealed by their historical data, and which is outside of their immediate experience.
■ Poor intelligence: Corporate entities are reliant on good intelligence if they are to be sufficiently aware of threats to safety. Intelligence relies on both formal information flows through the organisation and a myriad of informal personal exchanges at every level. These flows of information, which are so vital to safety assurance, are easily interrupted by poor working relationships, dysfunctional management structures, or mutual distrust.
■ Lack of transparency: In order for an organisation to be aware of the threats to safety, it needs access to information. It needs to understand the design of its equipment, how it might fail, and the consequences should this happen. Barriers to accessing safety-related information can include commercial confidentiality, poor retention of documents, or the lack of expertise needed to interpret technical data.
Chronic unease
To achieve a high level of safety, leaders need to maintain a state of constant wariness concerning the management of risk - a condition often described as ‘chronic unease’. Despite sounding like a nasty medical condition, chronic unease describes a condition of unrelenting watchfulness - a persistent suspicion that all is not well and that something could go horribly wrong at any moment.
Such a mindset is of very real value in an industry such as railways, where safety is reliant on numerous safety controls that interact in a complex manner.
In a study sponsored by Royal Dutch Shell, researchers Dr Fruhen and Professor Flinn interviewed senior managers in the oil and gas industry and identified four characteristics or habits of mind underpinning chronic unease: ‘safety imagination’, vigilance, pessimism, and a tendency to worry.
Those with a strong ‘safety imagination’ are able to imagine the catastrophic consequences of precursor events (i.e. low-frequency, high-consequence accidents). Those with vigilance tend to closely monitor the environment, picking up on even weak signals of a problem. Pessimism and worry are linked to a tendency to expect failure, and tenacity in pursuit of improved safeguards.
Time and time again, RAIB investigations highlight accidents that could have been avoided had the leadership team focused on better understanding the threats to the safety of their business and the consequential risk.
For this reason, I urge everybody with a duty to deliver a safe railway to take the time to think hard about the way that they are assuring themselves that the threats to the safety of the railway have been identified, and the consequent risk understood.
