[SystemSafety] Comparison of Confidential vs Non-Confidential Reporting Systems

[grivsta at gmail.com]

One of the reasons for the different approaches is that Aviation has
embraced a systems approach, where health care still focuses on blaming the
individual [1]. Within aviation when something does go wrong usually the
individual we want to blame is no longer a physical being. I don't believe
you can strangle a spirit. In the medical filed the clinician (doctor,
nurse pharmacist) can be 'held to account', however, society does not do
that very well. Society wants to 'get' the individual as that makes society
feel better. It may not always make the victim feel better [3]. Few
engineers set out to be bad, yet bad engineering does happen. The medical
world is the same; when doing your job you don't consciously think about
'if I do X incorrectly I will be fined or go to jail'. You just want to do
good work. I don't believe that blaming the individual will improve
safety.

There are many papers on how embracing the aviation approach to safety can
improve outcomes in the medical world [2]. Aviation has a 'no blame'
culture to encourage reporting. When the FAA decided to reverse this the
amount of reporting reduced. [3] A no blame culture needed to be restored
for improvements to be gained once again in Aviation.

Alvery's point that people have very little understanding of personal risks
in differing domains is quite true. Who would have thought that with the
recent focus on the safety problems of AVs that they are 2.5x safer than
surgical robots [4] or that at the moment people are up to 4000x safer than
AVs?

The small amount of reading I have done indicates that the systems approach
and how justice is delivered in Aviation has bee recognised to provide
safety improvement where other industries are less mature and have not
embraced this change. The medical world will find improvement if they make
the shift [5]  More learning ()in general) is required in the are of
reporting [6].


[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710114/
[2] https://www.healthaffairs.org/doi/10.1377/hlthaff.28.3.w479
[3]
https://www.routledge.com/Just-Culture-Balancing-Safety-and-Accountability/Dekker/p/book/9781409440604
[4]
https://experts.illinois.edu/en/publications/hands-off-the-wheel-in-autonomous-vehicles-a-systems-perspective-
[5]
https://www.bmj.com/bmj/section-pdf/186272?path=/bmj/339/7712/Analysis.full.pdf
[6] https://www.mdpi.com/2313-576X/4/4/46


On Thu, Oct 18, 2018 at 12:08 AM Mike Rothon <mike.rothon at certisa.com>
wrote:

> I am looking for some recommended reading on the respective merits of
> confidential and non-confidential (open?) reporting systems with respect
> to 'safety events'.
>
> Aviation is one sector that has generally embraced the confidential
> reporting approach, whilst anecdotally I hear that it isn't (yet) used
> so widely in the medical sector.
>
> In general, I am trying to understand why it is considered to be
> beneficial for aviation, but not necessarily elsewhere.
>
> For example, is it just a natural human desire to know 'who done it'
> [sic] that prevents wider adoption, or does the fear of being named and
> shamed encourage people to behave more 'safety consciously'?
>
> I have made the usual Google search, but with surprisingly few results.
>
> Thanks.......................Mike
> _______________________________________________
> The System Safety Mailing List
> systemsafety at TechFak.Uni-Bielefeld.DE
>
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