Incident Recall - to find the Events that did not get Reported
Incident recall is the to help people remember events that could have led to undesired
consequences. These unwanted events can help to learn and to improve the management system but unfortunately,
for one reason or the other, do not get reported.
Practically all accident / incident ratio studies show that there are many more incidents - unsafe of "substandard" acts and conditions - than
accidents. They form a large body of information to improve organizational performance, when reported. In
most companies, however, incident reporting is weak. The purpose of incident recall is aimed at uncovering
more of this valuable information.
One of the more well-known accident / incident ratio studies is the one that was carried out
under guidance of Frank E. Bird, Jr. in 1969. At that time Mr. Bird was working with INA (Insurance Company of North America) in
Philadelphia as Director of Engineering; prior to his position with INA, Mr. Bird was with Lukens Steel in
Coatesville, Pa. as the safety and health manager. In 1966, together with George Germain, he wrote the book
"Damage Control" linking material damage accidents to injuries and thus dramatically expanding the safety
The above study - the most extensive accident ratio study ever carried out - revealed that there
are many more incidents than accidents, many more opportunities to learn and improve.
Why are incidents not reported?
Many of us have experienced incidents, near-accidents or close calls. At work or at home. Many
of us did not share the information with others.
If everybody knew how important incidents are as part of an improvement process, many more would
be reported. But often, they are not. Some of the reasons why this important information is lost
Fear of discipline
Concern about the record
Concern about reputation
Fear of medical treatment
Dislike of medical personnel
Desire to avoid work interruption
Desire to keep personal record clear
Avoidance of red tap
Concern about the attitude of others
Poor understanding of the importance
Learning from unwanted events that did not get reported
The objective of Incident Recall is to uncover incidents that people "forgot" to report. The
overall objective is to get a sufficient number - all? - of incidents reported so that you can learn from
them. Incident Recall is part of that effort.
In order to learn from incidents, they need to be known and there are several sources, other
than Incident Recall, to find out about them:
Inspections normally are carried out at regular intervals. These are planned, formal inspections
carried out by individuals or by teams.
Checklists are often used to guide the inspection process and serve as memory joggers allowing
sharing of experience between the more skilled inspectors and those still learning the job.
During inspections substandard of unsafe conditions are noticed. These conditions did not occur
by themselves - they were caused, most likely because someone did something or someone did not do something
(right). Unfortunately, deviations noted (the "unwanted event") during inspections are normally not analyzed
for their causes. Normal practice is that they are corrected, probably noted on a form and that's about it!
If that is the way it is done, it is also an opportunity lost to prevent the same conditions from happening
Informal "inspections" have the same purpose of the formal inspection. Only they are not planned
and checklists are not used.
Behavior observations are like inspections. Only now they are directed at what people
do and how they do it. In practice, however, the people carrying out behavior observations often tend to
focus on conditions rather than what people do. Focussing on conditions is easier than observations and
addressing people about what they do wrong.
Critical task observations are observations of how critical tasks are being carried
out. These observations form part of training / instruction. They are a good way to see that these
tasks are properly being carried out according to procedures of work instructions - the "standard way of
doing the work" that should have been part of the training / instruction. Critical task observations form an
excellent source to find deviations that could lead to accidents. They are also a good means to see if
existing procedures, work environments or tools need to be adapted.
Unsafe or substandard acts / condition reporting systems
The substandard act / condition reporting could be included in the accident investigation protocol.
Basically there are two formal systems to report acts/conditions :
Both systems use a relatively simple form to be filled out. The form should go to a coordination point where a person decides whether or not the condition or act reported
should be further processed depending on the risk classification level
Accident or Incident Recall is a structured process of communication / interviewing to uncover
events that could have resulted in unwanted consequences - events that may be used for learning before they
The interviewing could be done by a supervisor/manager or by a staff person more experienced in
interviewing techniques. It could be done on a one-on-one basis or as a group exercise. The latter is
probably the better approach but requires a non-blame fixing culture in which people are attuned to helping
each other to prevent accidents.
Should you investigate all minor or no-loss events?
I do not think so. You want as many as possible reported and you want to record them for trend
evaluation and you want to know what these small losses cost you per period.
After they have been reported, recalled or imagined, use a risk classification tool to find the high potential (HIPO) events that could
lead to serious loss and carry out a cause analyses on those.
Giving too much attention to events that will not and cannot generate important losses may lead
to demotivation of people, including management.