swiss cheese model
At the heart of a safety system is culture, and a safe organisation is one which is open and ready to learn from mistakes. James Reason's Swiss Cheese construct is an academic, yet simple, model with which to support a learning safety culture.
An incident is an unplanned event that has a potentially adverse outcome for people or equipment. An accident is when that event results in an adverse outcome. The difference between the two is merely the outcome. Incidents therefore should not be ignored ' no-one got hurt', rather they should be treated as an opportunity to avoid replication and a potentially adverse outcome in the future.
The Reason model focuses not on the individual but on the organisational barriers that were breached to allow the incident to occur. So when an incident occurs we would appreciate it being reported. Our safety officer will interview a few of the folk involved, look at what we can do to prevent re-occurrence, brief the Board and make recommendations to the Team leaders.
It is not a punitive exercise - the intent is for us to learn.