This is the concluding part of a ten-part series of articles on Root Cause Anaylsis. Each article highlights the principles behind Sologic’s approach to solving complex problems (sologic.com). All articles are based on originals by Ed Wells, author of Sologic’s excellent e-book, ‘Better than Yesterday’.
“You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself” ELEANOR ROOSEVELT
Great organisations pride themselves on effective reporting. They create and utilise intelligent ways to record, present and share critical information – and they act upon it.
Whilst all great organisations do this, the aviation industry has become the benchmark for organisational reporting. Telemetric systems in aviation share real-time information, delivered in clear, digestible chunks. This allows key staff and organisations to stay ahead of an information curve that is sometimes the difference between life and death.
“Organisations should have clear reporting processes, organisation-wide communication and provide all staff with effective training. If staff feel reporting something that has resulted from their error or mistake is likely to lead to punishment, they are unlikely to speak up. Similarly, if they don’t receive feedback it’s easy to conclude the organisation isn’t interested in their report, so why bother reporting?” The Civil Aviation Authority (1)
Unfortunately, though, many organisations slip into the trap of assuming that a report is only effective if it holds every conceivable piece of information available. The result of this approach results in unwieldy, indigestible reports that few people read and even fewer understand.
Effective reporting is a different animal. An effective report will document the incident clearly, provide the key evidence and describe all the impacts on the organisation. It will include a simple visual analysis and concisely document any proposed solutions (including any that were rejected).
Effective reports provide a strong case for change, they are streamlined, timely and engaging. If they don’t clearly explain the key aspects of a problem and highlight what the organisation should do about it, the report will have failed. The enduring challenge is to get the key outcomes recognised and embedded into policies, procedures and training guidelines that really matter.
Continuing with the airline theme, Air Canada produced an effective report(2) on aircraft turnaround – specifically the potential for safety issues in a busy environment with people from different organisations working alongside each other and the additional considerations of other external influences such as weather, noise and time constraints. The report produced was short and direct, clearly stated the problem, the requirements, which actions were undertaken and what the outcomes were – notably a decline in the number of accidents.
Above all, great organisations recognise that their reporting system is the key (and sometimes the only) communication conduit between very diverse stakeholders. Therefore, any system of reporting must be easy to access; simple to understand and clearly demonstrate who will benefit from the change it demands. Without this, an organisation will dangerously limit their institutional learning
and fragment its corporate memory. Not learning from past mistakes is a sure-fire way to leave risk exposed.
Ask yourself:
Can staff easily gain access to reports that are pertinent to their role?
Will the output from your problem-solving generate reports, reveal trends and reduce future failures?
Key point:
If you don’t report well, the knowledge will be lost forever. Great organisations integrate effective reporting into their systems, build in accessibility and drive the sharing of this knowledge.
Reference:
(1) https://www.caa.co.uk/our-work/make-a-report-or-complaint/report-something/safety-reporting-guidance-for-aviation-employees/ accessed via the Internet on 31 July 2023
(2) https://www.hse.gov.uk/airtransport/case-studies/aircanada.htm accessed via the Internet on 31 July 2023