Catherine Baker, Director, CIRAS, explores how our decisions are influenced by our choice of inputs.

I recently hosted a panel session discussing the role of technology in keeping trackworkers safe. Technology has an important role to play, but it was fascinating that time and time again the conversation came back round to how it is only any use if the interactions between people and technology are working well. In the case of trackworkers, the most advanced protection system in the world is rendered useless if people are not where the technology thinks they are. The railway system is a complex interaction of fixed and moving assets, and the people who design, build, maintain and operate it. The system is the product of decisions over generations, together with those being taken every day, all by professionals in their own fields. How can we be sure that those decisions are not also being undermined by a view of reality that turns out not to be accurate?

ETHICAL DECISIONS?

As professionals, we take our responsibilities seriously so that our actions have a positive impact on our world. We wrap these up into codes of conduct and endeavour to take ethically sound decisions which are balanced and well informed by objective evidence. But is there more to this than our training and experience suggest?

Let’s unwrap the phrase ‘objective evidence’. We are rarely gifted with having complete, perfect information to inform a decision. That’s the nature of professional judgement. Wrapped up in that judgement is a choice about what input information matters, and what doesn’t. This may be conscious, but the danger zone is when our unconscious starts to classify information for us. However objective we think we are, we see the world through the filters of our own experience. Psychology meets engineering when quiet voices, unexpected information or weak signals are not picked up on, sometimes with devastating consequences.

The recently published RAIB annual report for 2020 included the following line; “An underlying theme in many of the investigations this year has been the divergence between what the management system said should be happening, and what was actually going on.”

Just like a technically advanced trackworker protection system, an engineering decision can be rendered useless if the inputs don’t reflect all aspects of reality.

LISTEN-UP

Whichever part of the infrastructure lifecycle you are involved in, are you listening out for the unexpected? This is true whether it is unusual data from a new remote condition monitoring system, or an off-the-wall question from a new apprentice. Both could be easily dismissed but if you stop and listen, really listen, it could open your eyes to a whole new perspective on your work.

At CIRAS, we listen every day to people from across the transport sector who raise concerns and suggestions that could lead to improvements in health, wellbeing and safety. Most are passionate about wanting to see improvements that will benefit themselves, their colleagues and passengers. Some call because fear prevents them speaking out openly, but the most common reason given is not feeling they would be listened to by raising issues internally.

It is noteworthy that in the last year, over half the concerns that have been raised with us relating to assets and infrastructure have been third party reports. This means they are raised by an employee of a company other than the one responsible for the asset. Listening to inputs from across the many interfaces in our industry is critical if we are to understand, to use the RAIB’s phrase, ‘what is actually going on’.

The NHS recently undertook a survey which included a question about whether staff felt safe to speak up. In response, the NHS National Guardian urged leaders to ‘listen to the silence’, to think about voices not represented in the survey, particularly where those voices might be in vulnerable groups who feel unable to speak up, perhaps because of their role, ethnicity, or contract terms. Listening to the silence can prompt us to think about the voices we are not hearing from, and the inputs we are therefore missing to our decisions.

The work of mathematician Abraham Wald during World War 2 provides a technical example of listening to this silence. Faced with the problem of how to improve the survival of bombers under attack and lots of data about where the returning aircraft had sustained damage, the military reached a natural conclusion that the parts of the plane sustaining most damage were those in need of reinforcement. Wald however was more interested in the data gaps. There was no data for the planes that did not return, and returning planes consistently had little or no damage to the cockpit or tail. Focussing on the data silences enabled him to save planes by pointing out that it was the cockpit and tail that needed reinforcement.

Whether missing data or missing voices, can we really claim that our decisions are ‘sound’ and ‘ethical’ if we have not actively sought to listen to the silence?

SPEAK-UP

What about if the shoe is on the other foot and you are the one with the information rather than the decision maker? It is right there in the PWI Code of professional conduct at 3.6:

Members shall raise any concern, either within the workplace or externally, about a danger, inadequately quantified or managed risk, malpractice or wrongdoing which affects others. Any such concern shall be reported to their employer or manager. If this does not address the concern, they should be aware and make use of existing company and industry sector regulatory reporting systems.

‘Of course I would speak up!’ is easy to say, and we really mean it. But what if you are the junior faced with experts who seem to be dismissive of the issue? Or you are unnerved that something is not quite right with a system, but it is outside of your competences so you could be mistaken. How far would you take your concern if decision makers don’t seem to get it? Internationally, there are major disasters where failure of the connection between those who knew and those who could act is cited in the investigations – Challenger and Deepwater Horizon are just two.

Closer to home, you will not have heard about the train accident caused by a warning system error last year, because it didn’t happen. System users reported through CIRAS that the warning sounds were not working as expected. Although it was an established system widely in use, the company owning the system listened and investigated to discover an unexpected compatibility problem in certain use cases.

When speaking up and listening are aligned, early warnings can prevent accidents. System owners may be experts, but if they don’t have access to the critical information that you hold, their decisions too are rendered ineffective.

FOLLOW-UP

A phenomenon that we saw more starkly than usual last year was the impact of communication about decisions. During March and April 2020 companies were implementing new risk controls relating to the pandemic so fast that keeping their people up to speed was a challenge. Someone might call us at the end of a shift with a concern they did not think was being heard, only to find that the company already had new controls planned that were implemented by the time they started their next shift.

In more normal times we have picked up concerns that asset faults are not being fixed, again only to find they were in hand but the people on the ground were out of the loop so did not feel they were being listened to. In one example this led to a whole new approach for providing visibility of how fixes were progressing.

If we want our decisions to be well informed by all the relevant voices, we need to tap into the virtuous circle of people knowing they have been listened to and therefore choosing to speak up again next time. The RAIB Annual Report 2020 states that ‘a positive, open and honest culture is also needed if leaders are to be properly informed, and protected from wishful thinking’. Closing the loop so people know they are being heard is critical.

CIRAS – HERE FOR YOU

The confidential reporting service provided by CIRAS is one tool in your toolbox for ethical decision making. If you find yourself in a position of needing to be heard but can’t do so internally, do call our hotline.
If you are the decision maker, where are your silences? Are you encouraging those voices to be heard through any one of the available industry channels?

Don’t forget – if you want to know whether someone has raised a concern confidentially on a topic you are working on, you can search reports and company responses on our website www.ciras.org.uk*.
Take a look, it’s your decision.

We are soon launching an upgrade to our website that will enable all staff of member companies to log in directly to view reports. Until then, you can access the reports via your CIRAS rep.

About the AUTHOR: Catherine Baker – Director CIRAS

Catherine heads up CIRAS, the Confidential Incident Reporting and Analysis Service, a not-for-profit organisation which has provided a confidential health, wellbeing and safety reporting line for workers in the transport and infrastructure sectors for the last 25 years. Starting from a science and analytical background, Catherine has held a range of senior roles in the transport sector, spanning policy, risk management and research, all connected by the thread of working to deliver better outcomes for businesses, their customers, and their people – particularly for health, wellbeing and safety. Having spent much of her career working with those taking decisions that impact safety outcomes, it is now a privilege to be enabling people on the front line, who often have the best first-hand knowledge of the hazards, to have their voices heard when they might otherwise stay silent. Hence helping the companies they work for to take better informed decisions.