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reported. Some of the factors contributing to the subjective nature of voluntary incident reports are
listed below:
1) Reporters must be familiar with the reporting system and have access to reporting forms or
phone numbers.
2) Reporters’ motivation to report may vary due to the following factors:
— level of commitment to safety;
— awareness of the reporting system;
— perception of the associated risks (local versus systemic implications);
— operational conditions (some types of incidents receive more attention than others); and
— denial, ignorance of safety implications, desire to hide the problem, or fear of recrimination
or even disciplinary action (despite guarantees to the contrary).
3) Different occupational groups see things differently, both in terms of interpreting the same event
and in terms of deciding what is important.
4) Reporters must be aware of an incident to submit a report. Errors that go undetected are not
reported.
c) Report forms. Typically, incident reporting forms induce bias (including bias against reporting at
all), for example:
1) A report form must be sufficiently short and easy to use so that operational personnel are
encouraged to use it; thus, the number of questions must be limited.
2) Completely open questions (i.e. narratives only) can fail to elicit useful data.
7-APP 1-2 Safety Management Manual (SMM)
3) Questions can guide the reporter, but they can also distort perceptions by leading the reporter to
biased conclusions.
4) The range of possible events is so broad that a standard structured form cannot capture all
information. (Therefore, analysts may have to contact the reporter to gain specific information.)
d) Incident reporting databases. Information must be categorized in accordance with a
predetermined structure of keywords or definitions for entry into the database for later retrieval.
Typically, this introduces bias into the databases, compromising their utility, for example:
1) Unlike objective physical flight parameters, descriptions of events and any causal attributions
are more subjective.
2) Categorization requires a system of predetermined keywords or definitions, therefore biasing the
database, for example:
— Reports are analysed to “fit” the keywords. Details that do not fit are ignored.
— It is impossible to create an exhaustive list of keywords for classifying information.
— Keywords are either present or not present, providing a poor approximation of the real
world.
— Information is retrieved according to how it is stored; hence categorization determines the
output parameters. For example, if there is no keyword called “technical failure”, then
“technical failure” will never be found to be the cause of incidents from that database.
— The categorization system creates a “self-fulfilling prophecy”. For example, many incident
reporting systems bias the keyword categorization towards CRM. Consequently, CRM is
often cited as both the cause of the problem and its cure (more CRM training will redress
the perceived CRM deficiency).
3) Much of the information in the databases is never retrieved once it is entered.
4) Given the generality of keywords, the analyst must frequently go back to the original report to
understand contextual details.
e) Relative frequency of occurrence. Since voluntary incident reporting systems do not receive
information of the type needed to compute useful rate figures, any attempt to put the incident in the
perspective of a frequency of occurrence vis-à-vis other occurrences will be an educated guess at
best. For valid frequency comparisons, three types of data are required: the number of persons
actually experiencing similar incidents (not just the reported incidents), the size of the population at
risk of similar occurrences, and a measurement of the time period under consideration.
f) Trend analysis. Meaningful trend analysis of the more subjective parameters recorded in incident
reporting databases have not been particularly successful. Some of the reasons for this are listed
below:
1) difficulties in using structured information;
2) limitations in capturing the context of the incident through keywords;
Chapter 7. Hazard and Incident Reporting
Appendix 1 7-APP 1-3
3) inadequate levels of detail and accuracy of recorded data;
4) poor inter-reliability of one report against another;
5) difficulties in merging data from different databases; and
6) difficulties in formulating meaningful queries for the database.
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8-1
Chapter 8
SAFETY INVESTIGATIONS
Investigation. A process conducted for the purpose of accident prevention
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Safety Management Manual (SMM) 安全管理手册(56)
