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Renborg, Bo; Jonsson, Klas; Broqvist, Kristoffer; Keski-Seppaelae, Sven
Swedish Nuclear Power Inspectorate, Stockholm (Sweden)2006
Swedish Nuclear Power Inspectorate, Stockholm (Sweden)2006
AbstractAbstract
[en] This work has primarily been done as a study of available literature about reporting systems. The following items have also been considered: the participants' experience of safety work in general and reporting systems in particular, as well as correspondence with researchers and organisations that have experience from reporting systems in safety-critical applications. A number of definitions of the English term 'near-miss' have been found in the documentation about safety-critical systems. An important conclusion is that creating a precise definition in itself is not critical. The main objective is to persuade the individuals to report perceived risks as well as actual events or conditions. In this report, we have chosen to use the following definition of what should be reported: A condition or an incident with potential for more serious consequences. The reporting systems that have been evaluated have all data in the same system; they do not divide data into separate systems for incidents or 'near-misses'. The term incident in the literature is not used consistently, especially if both Swedish and English texts are considered. In a large portion of the documentation where the reporting system is mentioned, the focus lies more on analysis than on the problem with the willingness to report. Even when the focus is on reporting it is often dealing with the design of the actual report in order to enable the subsequent treatment of data. In some cases this has led to unnecessary complicated report forms. The cornerstone of a high willingness to report is the creation of a 'no-blame' culture. Based on experience it can be concluded that the question whether a report could lead to personal reprisals is crucial. Even a system that explicitly gives the reporter immunity is still brittle. The bare suspicion (that immunity may vanish) in the mind of the one reporting reduces the willingness to report dramatically. Meaning that the purpose of the analysis of reports must be to stop the situation from occurring and not to find the 'guilty'. There are therefore serious problems with both disciplinary and legal sanctions as an aftermath of reports. It is strongly recommended that an individual should have only one system to report to. The processing of the report must be open and include recurring feedback to the reporter and the organisation. The management's dedication in the process of building trust is the driving force in a safety culture. All the reporters must have confidence in the processing of the report and feel comfortable with the reporting system - that is a 'No Blame Culture'. The need for a reporting system could be summarized by 'The organisation will never learn from mistakes not reported'
Original Title
Hantering av haendelser, naera misstag
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Source
Dec 2006; 38 p; ISSN 1104-1374;
; PROJECT SKI 200603014; Also available from: http://www.ski.se; 27 refs., 8 figs., 2 tabs.

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