Reporting for safety : towards a complexity framework informing the social construction of multi-level stakeholder behaviour

Abstract

The safe operation of complex socio-technical systems depends on the information that flows in each system. Safety activities in the aviation industry are managed through various components integrated by a safety management system. One of the main contributors to safety information is the safety assurance components promulgated by the International Civil Aviation Authority (ICAO). This includes the critical incident reporting system, which is a sub-system to the safety management system. Many resources go into establishing a reporting system and the subsequent investigation of incidents, but, at present, little is known about reporting behaviour and the factors in a socio-technical system that influence such behaviour. Better understanding of reporting behaviour could augment the aims of safety activities and lead to a re-alignment of safety focuses, by including additional perspectives regarding improved system safety. Prior research on critical incident reporting focused mainly on the relevant hardware and the practices in a reporting system. These are important components, but the efficiency of a safety management system depends to a large degree on how information pertaining to risks and opportunities in the system that might otherwise remain masked or hidden is identified and dealt with to improve the efficiency of the system. In this study, a social construction theory lens was used to obtain a richer understanding of the behaviour of critical incident reporters and other stakeholders in a South African Air Navigation Service Provider (ANSP). This theoretical lens was then expanded by applying complexity theory to the identified socially constructed themes, in search of a richer understanding of reporting behaviour in a safety management system. The existing literature does not explain the various influences from within the system, the industry and the organisation as a whole on reporting behaviour. Hence, a case-study methodology was adopted to navigate this uncharted landscape, using various focus groups and interviews. In addition to dealing with several organisational levels in a case-study fashion, the qualitative data were managed through inductive coding and continuous thematic content analysis to explore underlying explanations for the actions which safety stakeholders take or omit in dealing with safety-related data. Data were collected across three organisational levels: (i) the operators usually associated with the act of reporting; (ii) line managers as first-line recipients of critical incident reports; and (iii) senior-level management as strategic actors in the safety domain. A fourth data set was added for the purpose of comparing differences in the social construction of critical incident reporting at an operator level by interviewing operators exposed to a safety investigation. The data were collected in four distinct data sets, but the dominant themes that emerged suggest three compelling and distinct narratives. These were presented in three articles. The first article reports on the investigation of the social construction of reporting, focusing on the experiences of front-line operators and the factors they consider in deciding whether to report an incident or not. These experiences and considerations clearly emanate from the pivotal role these operators play in their execution of tasks that create and enhance safety. The results reveal the prominence of self-preservation beyond the commonly identified system demands, and the premium operators place on context when they determine which incidents they think should be reported. A model to illustrate the five competing consequences or demands in judging the reportability of incidents was developed on the basis of the data. The second article explores the social construction of reporting across three organisational levels and four stakeholder groups. The thematic analysis across these levels reveals several dimensions of safety, where the act of reporting serves both as an antecedent and as an outcome resulting from organisational influences. These dimensions lie at the core of systemic safety, which thrives on a purposive value contribution focus, a decentralised safety management approach, the centrality of reporting in a safety management system, and engaged relationships amongst peers and managers, as well as across organisational levels. This article includes a diagrammatic representation of how these dimensions interact and interrelate. Awareness of these relationships is essential in designing a reporting system. The third article reports on a final thematic analysis across all four data sets, by applying complexity theory to the construct of reporting. Four main themes emerged as drivers of the social construction of reporting behaviour. These are Safety Knowledge Management, Decentralised Safety Power Distance, Shared Safety Logic and the Social Construction of Safety/Efficiency. These themes were analysed using complexity theory to produce a framework for a reporting system that acts as a systemic safety enabler. The complexity framework offers the following: (i) a new vocabulary for reporting research; (ii) an alternative theoretical view for understanding reporting systems by acknowledging system complexity and conducting reporting-based research with socially constructed themes in mind; and (iii) a comprehensive list of elements for practitioners to apply in reviewing and/or designing a safety management system that goes beyond a focus on hardware and reporting practices.