Striving for Efficiency: Contradictions in Employee Involvement – Why Safety Reporting Fails

EMPLOYEE INVOLVEMENT - WHY SAFETY REPORTING FAILS

The final area of interest in our discussion of management behaviour is the apparent tension between employee involvement in the broader design of work and the implications for future operations. Management actions that seem to be inclusive of the workforce, such as quality initiatives and safety reporting, appear to represent a rational approach to issues but can often result in additional work and added restrictions and constraints on workers.

Safety reporting is a fundamental tool in safety management but is also a good example of this idea of seeking employee commitment while not always rewarding that apparent investment in safety. Having a ‘strong reporting culture’ is usually seen as a sign of a healthy safety culture in an organisation, and yet, under-reporting of events is common in any safety-critical domain that relies on worker feedback. Little research has been done on rates of under-reporting in aviation. In a study of a German carrier (Helsabeck, Schmidt-Moll & Schubert 2015) a questionnaire was administered to 86 pilots. The authors found that under-reporting rates differed according to the nature of the event. For significant events, such as landing with less than 30 minutes of fuel, reporting was 100%. Events that could be attributed to outside agencies, such as time pressure induced by organisational deficits, were reported on 94% of occasions. Adverse weather event reporting achieved an 82% reporting rate while events involving near-misses on the ground were reported on 33.3% of occasions.

In an attempt to quantify under-reporting, I looked at 1107 errors observed on a line operations safety audit (LOSA) in 2013. Three were deemed, by the observer, to be reportable events. Because of confidentiality rules, it was not possible to verify whether a safety report was ever submitted for the relevant flights. However, as no reports were submitted for routes between the relevant city pairs during the study period, I think it is safe to assume that the events went unreported. I then looked at the safety reporting for the audit period and identified comparable events. For example, floated or hard landings or deviations off track to avoid weather without АТС clearance were seen in both the safety data and the LOSA. By comparing the number of reports submitted over the study period with the occurrence rate in the LOSA data, I calculated the rate of under-reporting. For those events where there was a chance of being caught by a third party (i.e. АТС might file a report or the flight data analysis programme might pick up the event) there was a 12.5% reporting rate but where there was no chance of being observed by a third party then reporting was closer to 2%. In another study, I looked specifically at arrivals and departures into the airlines’ home port. This destination generated most data in both modes of sampling: all aircraft have to come home at some point. The reporting rates for three different fleets are given in Table 9.3.

There is quite an extensive literature across a range of domains on why safety reports are not submitted although, again, the specific evidence from aviation is limited. In the German study, the reasons for not writing reports differed between the short and long-haul pilots. For short-haul pilots, the effort required was the most frequently cited reason for not reporting. In the context of this chapter, negative feedback by their superiors was the next most frequent reason followed by the lack of any observed change as a result of reporting. For the long-haul pilots, negative response from managers was the biggest disincentive followed by the lack of any change as a result. Long-haul pilots commented that they generally felt reporting was meaninglessness and insignificant. Hutter and Lloyd-Bostock (2015) interviewed a sample of British pilots about reasons for not reporting. Once again, the effort needed and wariness about management responses were core themes. I fed my data on underreporting to groups of pilots and asked why they, specifically, might not submit a report. The effort, mistrust of management and the lack of any observable response were core themes. This idea of reporting being potentially harmful probably explains some of the differences shown in Table 9.3, reflecting cultural issues within fleets as reflected in management responses.

Of particular interest was the fact that many pilots talked about reporting as a variable, not a constant. As one pilot said, ‘the first time I encounter a problem

TABLE 9.3 Reporting Rates

I might report it but the next time I come across it I know what to do so why report it?’. Another training captain said that ‘If I’m doing a training flight with a new FO I might report something but if it was a normal line flight for me I probably wouldn’t’. The normalisation of operational challenges was commonplace. Some destinations were renowned for the unreliability of services and facilities, and crew simply stopped reporting issues ‘because there is nothing that can be done’. The idea that reporting is socially constructed also emerged from Hutter and Lloyd-Bostock’s work. Events, such as fatigue, became normalised and, so, the crew stopped reporting it. The formal ‘rules’ around reporting were of less importance than perceptions around how reports will be used. The authors found that younger pilots learn about reporting by participating in discussions with more senior captains. What we are seeing here is another form of culture. Social norms around reporting are communicated to the next generation of pilots.

The paradox of reporting is neatly captured in this encounter I had while running a reporting system for a small Scandinavian airline. Talking to one of the cabin crew about the gap between the reports submitted and the fact that I knew of events happening on the line that did not get reported her response was, ‘My job is to fix problems. When I’m just doing my job, why should I write reports about it?’. Reporting of events is required under rules issued by aviation authorities and is elaborated in company policies and procedures. The evidence, though, suggests that reporting is a negotiated process. The effort required to report is balanced against crew perceptions of benefit and personal risk. The resolution of this equation is seen in terms of the rate, coverage and quality of reports submitted. The reporting of hazards and safety- related events is considered to be the cornerstone of safety management which, in turn, is seen as part of a broader initiative aimed at incremental improvement. The benefit to the organisation is seen in terms of reduced risk through better defence against hazards and possible loss prevention. Unfortunately, the participating crew do not always see any advantage in reporting. Crew expend effort while running the risk of sanction yet rarely see any positive change that might make their jobs less demanding. Interestingly, commercial air carriers are required to have an approved safety management system and, therefore, the establishment of the scheme is a sunk cost. The actual effectiveness of the system is rarely measured and, so, there is little incentive to address the issues raised by the crew as barriers to reporting. This behaviour is suggestive of self-organised criticality, discussed in Chapter 3. In this view, protection is seen as a component of the cost of production. Organisations will accept a level of protection that is deemed adequate but does not impede production. Because protection represents an impediment, organisations migrate to a position in a notional ‘safety space’ where they are ‘safe enough’ at least cost. Addressing issues around the effectiveness of reporting represents an unnecessary additional cost when the condition imposed by the regulator - having a reporting system in the first place - has been met.

Workers respond to these apparent contradictions by building a stronger sense of identity within the workgroup rather than within the company as a whole (‘it is against them’) and reducing the emotional commitment to the company (‘screw them!’).