Filters and barriers in data collection

Only two of the six companies conducted near-accident reporting on a routine basis. At those two companies, the near-accident reports mainly contained data on technical incidents, deviations and causal factors. The lack of data on human errors was explained by the fact that the reporter s anonymity could not be guaranteed and by fear of disciplinary action. 

The different filters narrowed the scope of the companies learning from their experiences. They limited the types of accident prevention and the remedial actions that were taken and their timing. The focus in accident investigations, for example, on the incident rather than on the precursory deviations will direct the investigator towards remedies to stop the energy flow, i.e. protective devices. Workplace inspections mainly resulted in corrections of deviations. 

Let us analyse these findings in relation to Ashby s law of requisite variety. This law conveys an important message concerning the necessary conditions for us to be able to exercise full control of a system. If the available information on accident risks has a limited coverage, it will limit the variety of the action alternatives taken to control accident risks. The variety of the actions may well fall below the critical level the accident risk will remain at the same level or even increase as a result. Many opportnnities for accident control are lost if the investigator fails to identify how prodnction disturbances affect the risk of accidents. 

It further follows from Ashby s law that changes in production affecting the accident risk must be detected not only through accident reporting but 

It is obvious that there was significant improvement potential in many of the SHE information systems existing in industry at that time. The author conducted a similar study in the beginning of the 1990s (Kjellen, 1993). It involved an oil company that had implemented a SHE management system based on the ILCI principles (Section 5.7). It was interesting to study whether the application of modern SHE management principles would help the oil company to overcome some of the barriers and filters identified in the earlier study. 

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