Incident Recall

Incident recall is to help people remember events that could have led to undesired consequences. These incidents help to learn from accidents / incidents.

Practically all accident / incident ratio studies show that there are many more incidents - unsafe of "substandard" acts and conditions - than accidents. They form a great body of information to improve the working environment, when reported. In most companies, however, incident reporting is often weak and the purpose of incident recall  is aimed at uncovering more of this valuable information.

One of the more well-known accident / incident ratio studies is the one that was carried out under guidance of Frank E. Bird, Jr. in 1969. At that time Mr. Bird was working with INA (Insurance Company of North America) in Philadelphia; prior to his position with INA, Mr. Bird was with Lukens Steel in Coatesville, Pa. as the safety and health manager. In 1966, together with George Germain, he wrote the book "Damage Control" linking material damage accidents to injuries and thus dramatically expanding the safety scope.

The above study - the most extensive accident ratio study ever carried out - revealed that there are many more incidents than accidents, many more opportunities to learn and improve.

Why are incidents not reported?

Many of us have experienced incidents, near-accidents or close calls. At work or at home. Many of us did not share the information with others.

If everybody knew how important incidents are as part of an improvement process, many more would be reported. But often, they are not. Some of the reasons why this important information is lost are:

• Fear of discipline
• Concern about the record
• Concern about reputation
• Fear of medical treatment
• Dislike of medical personnel
• Desire to avoid work interruption
• Desire to keep personal record clear
• Avoidance of red tap
• Concern about the attitude of others
• Poor understanding of the importance

Incident recall - part of an effort

The objective of Incident Recall is to uncover incidents that people "forgot" to report. The overall objective is to get a sufficient number - all? - of incidents reported so that you can learn from them. Incident Recall is part of that effort.

In order to learn from incidents, they need to be known and there are several sources, other than Incident Recall, to find out about them:

Inspections

Inspections normally are carried out at regular intervals. These are formal inspections carried out by individuals or by teams. Checklists are often used to guide the inspection process and serve as memory joggers allowing sharing of experience between the more skilled inspectors and those still learning the job. During inspections substandard of unsafe conditions are noticed. These conditions did not occur by itself - they were caused, most likely because someone did something or someone did not do something (right). Unfortunately, deviations noted (the "unwanted event") during inspections are normally not analyzed for their causes. Normal practice is that they are corrected, probably noted on a from and that's about it! If that is the way it is done, it is also an opportunity lost to prevent the same conditions to happen again.  

Informal "inspections" have the same purpose of the formal inspection. Only they are not planned and checklists are not used. This is the  

Behavior observations

Behavior observations are like inspections. Only now they are directed at what people do and how they do it. In practice, however, the people carrying out behavior observations often tend to focus on conditions rather than what people do. Focussing on conditions is easier than observations and addressing people about what they do wrong.

Critical task observations are observations of how critical tasks are being carried out. These observations form part of training / instruction and are a good way to see that these tasks are properly being carried out according to procedures of work instructions - the "standard way of doing the work" that should have been part of the training / instruction. Critical task observations form an excellent source to find deviations that could lead to accidents.

Unsafe or substandard acts / condition reporting systems

The substandard act / condition reporting could be included in the accident investigation protocol. Basically there are two formal systems:

• paper system
• electronic system 

Both systems use a relatively simple form to be filled out. The form - see example above taken form RMS-Incident - goes to a coordination point where a person decides whether or not the condition or act reported should be further acted upon. The person reporting the act or condition should be notified about the decision. Once the reporting of the act or condition is accepted the workflow is similar to the accident investigation process and includes risk classification, cause analysis and remedial action development and follow-up.

Incident recall

Incident Recall is a structured process of communication / interviewing to uncover events that could have resulted in unwanted consequences - incidents that may be used for learning before they get lost.

The interviewing could be done by a supervisor / manager or by a staff person more experienced in interviewing techniques. It could be done on a one-on-one basis or as a group exercise. The latter is probably the better approach but requires a non-blame fixing culture in which people are attuned to helping each other to prevent accidents.

When carrying out the interviews, consider the following:

• privacy preferred, avoid distraction
• decide on the way to select people to be interviewed
• adjust interview time - do not waste time on unimportant incidents
• no-fault assurance is a must - blame fixing will kill the exercise
• prepare for the interview - make a checklist of tasks, procedures, work environments likely to be associated with incidents
• Conduct the interview and consider:
• • putting the person(s)at ease
  • explain purpose and importance of recall
  • emphasize no-blame fixing policy
  • high-light importance of recall for all involved, organization, employee, colleagues, family
  • explain process of the interview, use of checklist
  • review understanding of the incident
  • discuss possible causes and remedies
• use incident recall in exit interviews, including contractors and temporary personnel