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Proceedings of the TSB Transportation Safety Summit

Executive Summary

Encouraging the flow of safety information

Safe operations, in any mode of transportation, are achieved when risks are continually identified, evaluated, and mitigated. The unrestricted information flow throughout the organization is critical to this effort. Information flow, in turn, depends on a supportive safety culture and effective safety management processes.

This report provides a detailed account of the two-day Transportation Safety Board (TSB) Transportation Safety Summit, held in Ottawa on April 21-22, 2016. More than 70 senior executives and leaders representing operators, labour organizations, industry associations, and regulators attended the summit. Through a combination of presentations, expert panels, and facilitated working groups, the summit provided a forum to hear experiences and best practices and to exchange and challenge ideas about how to encourage information flow to improve safety.

In this report you will find

Introduction and background

This report provides a detailed account of the two-day TSB Transportation Safety Summit, held in Ottawa on April 21-22, 2016. This introductory section explains the summit, including the rationale for the themes explored at the summit and an outline of the summit's structure.

Following this is a brief summary of the key messages from all of the presentations, expert panels, and breakout sessions. Links to the materials used by the various presenters are provided.

All of the output from the 4 breakout sessions, during which participants provided their thoughts on the themes of the summit, are included as appendices to this report.

Theme of the Safety Summit: Information Flow

Information flow was chosen as the theme of the TSB Transportation Safety Summit because, in the words of TSB chair Kathy Fox in her opening remarks,

Over the past few years, TSB investigations have identified multiple examples where risks in the transportation system went unaddressed. In some cases this was because an issue was not identified—either the data was not available, or it was not being mined. In other cases, issues were identified, but weak or missing processes for managing safety contributed to an inability to take action.

Effective information flow, which allows risks to be identified proactively and mitigated, relies on safety management processes that collect data and turn them into outputs having all the characteristics of good information. Good information provides answers to questions the receiver needs answered, is timely, and is presented in a way that the receiver can use.Footnote 1

Equally critical is a safety culture that actively encourages people to provide data through safety management structures and to make maximum use of the information emerging from them. Information flow is maximized in generative safety cultures characterized by a high level of trust, focus on a common mission, and a level playing field with a low level of hierarchy.Footnote 2

Given the importance to effective information flow of both safety culture and safety management, the summit explored both topics over the 2 days.

Structure of the Safety Summit

More than 70 senior executives and leaders representing operators, labour organizations, industry associations, and regulators attended the summit. It aimed to provide a forum to exchange and challenge ideas about how to encourage information flow to improve safety. To that end, the summit included a number of different session formats:

An outline of the sessions held during the summit is provided below.

For the breakout sessions, participants were divided into 8 groups. For the first 3 sessions, groups were multi-modal, while the fourth session consisted of mode-specific groups. Facilitators from the TSB managed the breakout sessions; input was captured on flip charts and simultaneously by a note taker. Facilitators were instructed to capture ideas, to the greatest extent possible, in the words of the participant. The information presented in the appendices to this report includes the notes compiled during the breakout sessions, with minimal editing.

Outline of the safety summit sessions

Keynote address

Getting Information Flow: Ron Westrum, Eastern Michigan University

Presentation 

Statement of Safety Issue Support – Review of Findings and Systemic Risks: Faye Ackermans, Member, TSB

First expert panel

Moving organizations toward a cooperative, trust-based relationship

Breakout discussion 1

How can we move organizations toward a just culture?

Keynote address

Case Study from Health Care: Jack Davis, Chairman and CEO, CEO.Mobile Inc.

Breakout discussion 2

Maintaining confidence in your system while maintaining information flow: What would you do?

Second expert panel

Using leading indicators or data sources/processes for a proactive and predictive approach

Breakout discussion 3

How do you find trouble before trouble finds you?

Presentations
Breakout discussion 4

How do we maximize the use of voice/video while balancing rights and obligations?

Day 1: Information Flow and Safety Culture

Keynote address: Getting Information Flow

Professor Ron Westrum from Eastern Michigan University delivered a keynote address on the topic of improving information flow in organizations. He described information flow as the process of getting information from the people in the organization who have it to the people who need it, and making effective use of that information.

Professor Westrum used a number of examples to illustrate 3 common problems related to information flow in organizations:

These issues can be overcome by developing a state of "requisite imagination" where people are encouraged to "imagine how and why things might go wrong, and then probe deeply along potential fault lines."

Relating requisite imagination and information flow to organizational culture, Professor Westrum emphasized that information flow will be maximized in a generative culture where people believe they belong to a common enterprise. To report faint signals, employees must feel that they are aligned with the organization's management, have (or can get) the key expert knowledge to determine if something is wrong, and feel empowered to speak up.

Such a culture can be developed by focusing on the organization's mission and creating a level playing field with minimal hierarchy.

Professor Westrum concluded by stating that developing a workplace focused on cooperation requires a high level of trust and respect throughout the organization.

Presentation: TSB Findings Related to Information Flow

TSB Board member Faye Ackermans presented a summary of TSB findings included in recent reports that illustrate the issues the Board has been seeing in the areas of information flow, safety culture, and safety management.

As shown in the table below, 134 reports from all 4 modes were reviewed; 22 of these contain findings related to information flow (IF). The reports included 21 findings as to cause and 29 findings as to risk.

Table 2. Reports reviewed
Mode Period Reports reviewed
(had IF findings)
Causal findings Risk findings
Pipeline 2013–2014 3 (2) 3 4
Rail 2011–2014 58 (6) 6 5
Marine 2012–2014 35 (7) 4 9
Air 2013–2014 38 (7) 8 11

These findings were linked to 2 broad types of problems related to information flow: either information was not flowing through the organization, or information was flowing but risks were not being mitigated. Seven key themes were identified across these 2 areas, as outlined below.

Information not flowing

In cases where information was not flowing, the reasons fell under 4 main themes:

Information flowing but risks not being mitigated

In cases where risks were not mitigated despite information flowing, the reasons fell under 3 main themes:

Specific examples of investigations that illustrate how these issues contributed to unsafe conditions not being addressed were presented on posters displayed throughout the summit.

Expert panel: Moving organizations toward a cooperative, trust-based relationship

This expert panel provided an opportunity for participants to hear, first hand, how 3 organizations have worked to move toward a cooperative, trust-based relationship in managing safety. Speakers represented VIA Rail, NAV CANADA, and BC Ferries.

Breakout discussion 1: How can we move organizations toward a just culture?

The purpose of this session was to identify the means to develop a just culture by capitalizing on opportunities and overcoming obstacles. Participants were asked to brainstorm on both of these areas before devoting their attention to identifying how the most important best practices could be implemented and challenges overcome.

The full output from this breakout discussion is presented at Appendix A. The key themes are summarized below.

Key themes and messages from Session 1: Trust and respect

The discussions during this session strongly echoed the themes of commitment, collaboration, trust, and respect described in the keynote address and by all of the expert panellists.

In terms of best practices, communication and collaboration stand out as critical themes for moving toward a just culture. Specifically, participants highlighted senior management commitment, which is demonstrated through actions, measurable results, and resources dedicated to organizational learning. The importance of actively involving people at all levels of the organizations in safety processes was also stressed.

On the other hand, the discussion about obstacles to moving toward a just culture revealed the challenge of overcoming existing cultures involving blame and fear by actively building trust through collaboration. The importance of a frank and honest appraisal of the current culture, combined with ongoing commitment, collaboration, and communication to overcome mistrust and fear, were emphasized.

Keynote address: Case Study from Health Care—Part 1

Jack Davis, chairman and CEO of Mobile Inc. and former president and CEO of Calgary Health Region, provided a detailed analysis of a case involving a medication error that led to the death of 2 patients. The presentation was delivered in 2 parts. In the first part, Mr. Davis described the events that took place in the case study; participants then participated in the second breakout session.

Breakout discussion 2: Maintaining confidence in your system while maintaining information flow

The purpose of this session was to encourage an open and frank discussion about the limitations of discipline to change behaviour and how to maintain fairness and transparency in safety processes. Participants were asked how they would respond to these events in order to balance 2 competing priorities—being seen to be responding to events while encouraging information flow to prevent recurrence.

The full output from this breakout discussion is presented at Appendix B. The key themes are summarized below.

Observations on key themes and messages from Session 2

Two observations clearly stand out in reviewing the output from this breakout session:

Taken together, these observations clearly demonstrate that all of the groups embraced the values and beliefs needed to establish a just culture. Specifically, they indicate that all of the groups believed that errors are a symptom of issues within a system—at least when dealing with a case study of an external organization that is made up of trained professionals in whom we regularly place a high degree of trust. Further, they clearly communicate the belief that efforts to address these systemic issues will allow these same trusted professionals to work effectively and safely.

These observations are particularly interesting in the context of observations from Session 1, where communication and collaboration were identified as the key building blocks of trust. Taken together, it is clear that, at a philosophical level, the values and beliefs that underpin a just culture are widely held. At a practical level, however, the biggest challenge identified in terms of bringing about a just culture was the need to build trust and respect in organizations that may have a history of blame.

The second part of the keynote address described the approach taken to do just that in the Calgary Health Region following the event.

Keynote address: Case Study from Health Care—Part 2

In part 2 of the keynote address, Mr. Davis outlined the steps taken to identify and address the issues that led to the medication error while reassuring stakeholders that sufficient action was being taken.

In the end, the actions Mr. Davis described are consistent with the actions identified by all 8 of the breakout groups at the safety summit. Individuals involved in the events were off work with pay while investigations were ongoing. They were also provided with counselling and support, and returned to work with no disciplinary action being taken. At the same time, there was a significant level of collaboration and cooperation with staff to identify means to prevent recurrence and open communication with all stakeholders to share lessons learned.

However, Mr. Davis also described significant challenges in taking these actions. Echoing key themes from earlier in the day, he identified that overcoming an established culture of blame required significant effort. He said, "Our culture was the problem," describing the existing culture as hierarchical, focused on individual responsibility, lacking a sense of system, being organized for failure, and eliciting a shame and blame response when faced with human error. He emphasized that the system had to change, because an inappropriately punitive system drains energy and contributes to low morale; people with low energy and low morale cannot care and therefore cannot effectively contribute and collaborate to improve the system.

Overcoming this culture of blame required a lot of effort. Some helpful initiatives included

Mr. Davis concluded by summarizing the impact these efforts to change the culture had on the system. People were more confident and more engaged, which created more willingness to participate actively in improving the health care system. Echoing the results of the first breakout session, therefore, a frank and open assessment of the existing culture facilitated a concerted effort to build trust and respect, resulting in a more effective safety culture where information was flowing.

Day 2: Information Flow and Safety Management

Expert panel: Using leading indicators for a proactive and predictive approach to safety

This expert panel offered participants concrete examples of the types of proactive, predictive processes and data that organizations were using to identify safety issues.

Breakout discussion 3: How do you find trouble before trouble finds you?

During this breakout discussion, participants were asked to brainstorm on the following issue: "To help people get better at identifying and mitigating hazards without having incidents or accidents, we need to…." They were then asked to identify the main themes in the ideas identified.

The full output from this breakout discussion is presented at Appendix C.

Observations on key themes and messages from Session 3

To provide a summary of the ideas presented in this breakout session in the context of the safety summit, a number of the ideas presented in Appendix C have been organized in the table below. They are categorized according to the issues associated with information flow identified in the TSB review of occurrences. This is not an exhaustive list, but presents some of the ideas or possible solutions identified.

Table 3. Summary of the ideas presented in this breakout session
Problem Because Ideas to overcome
Information not flowing Risks are accepted as part of the job
  • Reward the use of stop work protocols;
  • Periodic reviews of environment to identify new safety risks;
  • Communicate top safety risks;
  • Encourage chronic unease—requisite imagination;
  • Job safety analysis for specific tasks;
  • Job safety briefings before tasks.
Unsafe practices are condoned in a poor safety culture
  • Need generative culture to enable collection and use of data;
  • Take action to address unsafe practices;
  • Communication, collaboration, and celebrating successes.
Weak incident reporting or investigation processes did not identify risks, and opportunities to mitigate were missed
  • Good risk assessment processes;
  • Independent audits of safety processes;
  • Benchmarking of safety processes against competitors.
Safety management practices did not exist, or existed only on paper
  • Clear triggers for risk assessment;
  • Training people in safety management processes, including risk assessment. These are perishable skills that need to be reinforced;
  • Feedback provided to people reporting safety issues to encourage further reporting.
Information flowing but not leading to risk mitigation Weak safety processes did not facilitate risk mitigation
  • Risk assessment process with clear triggers;
  • System to follow through risk assessment mitigations to completion;
  • Data mining—effective data analysis.
Information did not reach the right people
  • Communication, collaboration, regular safety meetings;
  • Address obstacles to using data.
Design parameters were not recognized as potentially problematic
  • Effective risk assessment processes with clear triggers.

Presentation: Expanding the Use of On-board Voice and Video Recorders

Kirby Jang, Director, Rail and Pipeline Investigations for the TSB, delivered a presentation on the use of voice and video data in locomotive cabs. He reviewed a number of investigations that were hampered by the lack of on-board voice and video recordings, and outlined the Board's previous recommendations and Watchlist calling for the mandatory installation of this technology. He then gave an update on the status of the joint TSB–Transport Canada study on the use of locomotive voice and video recorders.

Presentation: Use of Voice and Video Recorders—Balancing Rights and Obligations

Jean Laporte, chief operating officer of the TSB, presented on the current regulatory framework for the use of voice and video recorders and the protections afforded these recordings by the Canadian Transportation Accident Investigation and Safety Board Act (the Act). Acknowledging that the world has changed since the Act came into force, he outlined the rights and obligations of a range of stakeholders that must be considered in any future discussion of how such data could be used to advance safety.

He went on to outline a number of questions that must be considered, including

Advocating a thoughtful approach to changes to the regulatory framework, Mr. Laporte concluded his presentation by saying, "We all have some thinking to do in order to prepare and be ready, because there are no easy answers to all these questions. Once we open the door, it will be very difficult to close it. We therefore need to do things right the first time."

Breakout discussion 4: How do we maximize the use of voice/video while balancing rights and obligations?

The full output from this breakout discussion is presented at Appendix D. The key themes are summarized below.

Observations on key themes and messages from Session 4

The uses that participants identified for voice and video data varied widely, and included incident investigation, training, and normal operations monitoring. Recognition of the value of voice and video data to improve safety was not universal; some participants questioned whether it would have a value to improve safety or whether organizations would be willing to invest in the technology if the use of the data was limited.

Obstacles to the use of voice and video data echoed key themes heard in other breakout sessions, including trust and the need for a common understanding of the limitations and benefits of the data.

Appendices

Appendix A: Output from Session 1

How can we move our organizations toward a just culture? Barriers and opportunities

The purpose of this session was to identify the means to develop a just culture by capitalizing on opportunities and overcoming obstacles. The session followed the keynote address by Professor Westrum and the panel discussion on safety culture, during which 3 speakers shared their experiences working to transition their organizations toward a just culture.Footnote 3

Objective

Identify means to capitalize on opportunities and overcome barriers in moving toward a just culture.

Process

  • Brainstorm best practices.
  • Brainstorm obstacles.
  • Identify how to capitalize on most promising best practices.
  • Identify means to overcome most significant obstacles
  • Repeat 3 and 4.
  • Identify points to report back to plenary.

Step 1: Brainstorm best practices

Participants were asked to identify best practices in moving an organization toward a just culture. The ideas generated for all 8 breakout groups are as follows:

Step 2: Brainstorm obstacles

Next, participants were asked to identify obstacles to moving an organization toward a just culture. The ideas generated for all 8 breakout groups are as follows:

Step 3: Identify how to capitalize on most promising best practices

Third, groups were asked to identify 1 or more of the most promising best practices from step 1 and identify how these could be implemented. The best practices selected and ideas for all 8 breakout groups are as follows:

Table 4. Best practices and ideas for implementation
Best practice How to implement
CEO signed policy on non-disciplinary self-reporting
  • Self-explanatory
  • Selling it
  • Feet on the ground
  • Speak as senior leader
  • Walk the talk
  • Live by it
  • Ensure employees read it
  • Policy becomes the culture
Senior management feet on the ground
  • Plan it
  • Prepare it
  • KPI it (make it a key performance indicator)
  • Formal reporting process: 2-way reporting
NAV CANADA process
  • Determine what is disciplinary and what is not
  • Collaborative process
  • Communicate process
Management has to believe in it to support it
  • Education
  • Accountability
  • Good leadership (do not impose it, show the way)
  • Walking the talk (do not just post the policy, put it on the agenda, talk)
  • Leadership must be visible (best information from lunchroom; be on their turf)
  • Statistics and results
  • Having the right metrics
  • Set priorities to avoid initiative overload
Leadership at each level
  • Run the safety management process
  • Must have the resources
  • Communication, dialogue on events
Safety promise and defining what the organization means
  • Must have resources
  • Buy-in, involve the employees
  • Visible and communicated results from the safety policy being actioned—continual
Commitment/communication from the top—living the culture from the highest level of the organization
  • Early communication with employees
  • Show commitment through actions
  • Eliminate behaviours counter to just culture
  • Focus on benefits of just culture
Provide strong examples
  • Lead by example
Critical incidents
  • You learn from your mistakes
  • Resources to identify the root causes and understanding why it happened, but also how to prevent it
  • Talk is cheap; must demonstrate and commit with resources; take action
Self-policing
  • Safe—feeling supported: individual failures vs. organization
  • Reporting—culture—front line; responsible to manage front-line challenges—report all
  • Everyone reporting
Leadership (near miss reported)
  • Everyone passionate—walking the talk
Not specifically identified
  • Making sure the employee groups and management group are engaged in discussions
  • Awards program: recognition and positive reinforcement
  • Defining critical rules, processes, and communicating them
  • Drilling down extensively on what happened on each incident. Tracking employee records. Safety is clearly communicated; extensive training—holding people accountable because they have been trained
  • Management backing decision of employees for taking safe decisions
  • Instill sense of professionalism
Not specifically identified
  • Consensus and buy-in
  • All stakeholder-agreed definition of just culture
  • Definition has to be agreed upon
  • Table talk: disagreement about saying "just culture" versus "fair culture"
  • Understand where you're at from top to bottom
Vision is important
  • Engagement and journey is important
  • Find what's in it for them?
  • They need to be part of the decision process
  • It's got to be better
  • Transparency (total)
Collective recognition
  • Agreed upon definition of just culture is the best practice/solution
  • Assessment (need consensus of assessment)
  • Analysis of situation
  • Engagement is process
  • Trust is the outcome

Step 4: Identify means to overcome the most significant obstacles

Finally, groups were asked to identify 1 or more most significant obstacles and identify how these could be overcome. The obstacles selected and ideas for all 8 breakout groups are as follows:

Table 5. Significant obstacles and how they might be overcome
Obstacle How to overcome
Resistance to change
  • Repeat message
  • Explain why
  • Support change
  • Constant executive-level engagement
  • Sense of urgency
  • We don't plan
Culture of blame
  • Educate
  • Hard look in the mirror
  • Recognize it exists
  • Learn to trust
  • Create an environment to trust
  • Humility
  • Open dialogue; engage
Hierarchy
  • None identified
Trust (developing trust)
  • Clear goals
  • Empathy
  • Commitment
  • Transparency/openness
  • Keep your word
  • Make the necessary changes (tough to do; may be in the eye of the beholder)
Legal process/systems
  • Running the safety management processes, documenting, and presenting to the regulator
  • Keep the safety subject matter experts in the room/process as long as possible. And keep the others out as long as possible.
  • Dialogue
  • Consideration of the larger goal of the safety management system
  • Lean toward the non-punitive
Fear of change/denial/resistance
  • Emphasize the benefits of just culture
  • Frequent and open communication
  • A commitment to allocate sufficient resources: fiscal, human and time
  • Education
  • Seek out leaders from both employees and management to bring message forward (i.e., champions from both sides)
  • Measure results
  • Celebrate success
Lack of trust
  • Safety workshops—communication
  • Need to convince staff that you are doing what you are saying, believe it, and keep showing them that you are doing what you are saying
  • Involvement at all levels (management and employees in same room)
  • Education
Fear culture
  • Listening (past the no)
  • Understand where it comes from
  • Provide the safe space
  • Follow up on incidents and communicate that follow-up with everyone
Silos
  • People must be engaged, must share the big picture; communication plan
  • Build bridges—work in someone else's job
  • Follow-up necessary
  • Employee exchanges; place them in their objectives
  • Ensure that everyone understands how their work fits in with the organization; where everyone fits in with the organization
Resistance to change
  • Involve employees—feel part of change
  • Feel full support at all levels
  • Down and back up (vice versa)
  • Practical beats process if it makes sense
  • Ownership and empowerment all the way through
  • Recognize success when working—no black hole
Not specifically identified
  • Holding people accountable
  • Understanding everybody's perspective and have training on that (on how long until track is ready? Really means just that; not putting pressure or asking to take unsafe shortcuts)
  • Right people in the right spot—reorganizing?
  • Making them part of the solution, instead of imposing
  • Training
  • Communicate and be consistent in your message
Agree on definition
  • Need to consult
Requisite imagination
  • Easy to do after the fact
  • Hindsight is 20/20—but how do you prevent the occurrence?
Lack of alignment
  • Depends on size; easy when directed
  • Most difficult for some
  • Self-exclusion—set people adrift if they don't align
Lack of trust
  • Will was there—trust was not
  • Trust was there for some

Appendix B: Output from Session 2

Maintaining confidence in your system while encouraging information flow—what would you do?

The purpose of this session was to encourage an open and frank discussion about the limitations of discipline to change behaviour and how to maintain fairness and transparency in safety processes. It followed the first part of a keynote address by Jack Davis, during which a health-care case study was presented (involving a drug administration error).Footnote 4

Objective

To encourage an open and frank discussion about the limitations of discipline to change behaviour and how to maintain fairness and transparency in safety processes.

Process

  • Brainstorm actions you would take immediately and sometime later.
  • Identify the actions where group was in agreement or there was differences of opinion.
  • Identify the most cohesive and the most contentious idea to report back to plenary.

Steps 1 and 2: Actions to take and level of agreement among group

Having received the information about what happened in the case, participants were asked to discuss what actions they would take, in the immediate term and sometime later, to handle the situation. They were asked to keep 2 competing demands in mind—appearing to be taking action while encouraging the flow of safety information.

After identifying the actions, groups were asked to identify the degree of agreement on the action, specifically identifying those actions where there was full or close to complete agreement, some difference of opinion, or very little agreement.

The actions identified for all 8 groups are described in the table below, and categorized by the degree of consensus of the group specified.

Table 6. Actions to take immediately or later, showing degree of consensus when any was specified
Immediate actions Sometime later
Close to complete consensus of the group was specified on the following items:
  • Cross check procedure
  • Hire a crisis communication firm
  • The CEO is to be seen dealing with it
  • Buy time
  • Empathy
  • Organize communication
  • Ensure risk is illuminated or controlled
  • Launch internal investigation
  • Rally troops – demoralized troops
  • Facts not opinions
  • Reach out to NOK
  • Obtain clear facts
  • Communicate condolences
  • Communicate the intention of the process to investigate
  • Stop the damage, identify scope, deal with the immediate hazard in your system (with what you know)
  • Critical incident stress management for staff /employees & families & affected
  • Activate Emergency Response Plan
  • Monitoring others communications & speculations
  • Activate emergency response plan including:
    • Activate emergency response team
    • Stabilize facility in measured way
    • Stop dialysis if possible
    • contact board, insurance, Public relations/Legal council
    • Notify insurance underwriters
  • Involved in the event, family support and separate isolate
  • Commence plan.
  • Remove the individual from service. (You don't want them to badly influence others) and conduct investigation
  • Inventory check (in the Heatlh Care case) – are there any drugs similar? Scope of type of medication. Done across the company
  • Lock out and Tag out
  • Ask them what happened to understand their side of the story
  • Do staff meeting; to make sure they know what happened and make sure they know to follow policies. Cross check the procedures 
  • Prepare communiqué.
  • Bring in CISM support
    • Take care of your people
    • If they want to go home – go; or take care if they don't want to come in
  • Activate situation centre
  • Shut down operation that caused accident in first place until they have a review
  • Remove the people in the name of safety – not because of punishment – protecting hospital
  • Move/transfer patients
  • Report to necessary authorities
  • News conference
  • Fill the void
  • Shape messages
  • Reach out to the families
  • Bring third party support – to isolate ICU team who was working – don't want to be seen as protecting itself
  • Kick off investigations asap – with a recognized expert for the investigation
  • Make contact with other affected parties – suppliers – service providers (e.g., Baxter)
  • Communicate with union – protect people
  • Notify police

Some consensus of the group was specified on the following items:

  • Deploy to the site (if possible)
  • Consider risks analysis: safety stand down (not really disagreement but was pointed out that not every organization can stand down completely)
  • Whatever happened need to address the issue; if it is removing the person
  • Apologize and say that you are looking right into it
  • Do something to differentiate that medication from the rest so that staff know about it
  • Stop dialysis

Little consensus of the group was specified on the following items:

  • Call the manufacturer and ask that they contact everywhere they delivered it to advise

No consensus of the group was specified on the following items:

  • Get drug packages clearly marked.
  • Take away opportunity to make this mistake again
  • Establish a procedure
  • Call producer to find out why the packaging was as existed
  • Investigate what happened
  • Determining if workload or fatigue was an issue
  • How to make sure it does not happen again
  • Remove the immediate risk
  • Channel the communications through one place to avoid mixed messages
  • Taking care of the people - EAP – employee support (involved employees on leave / substitution) + family relations
  • Develop internal and external communications plan
  • Do not jump the gun … avoid placing the blame
  • Reach out to involved parties (Regulators, coroners)
  • Set up incident command center
  • Immediate communications to other hospitals
  • Involve legal services (… claims, insurance)
  • Stop action until I am comfortable (… or you can control the situation)
  • Was it the right product in the right box?
  • Provide support for people (internal) investigating
  • Manage the media, social media, regular media
  • Communicate with employees & regulators
  • Transparent, tell the truth, manage speculation
  • Take personal responsibility
  • Communicate internally about the realities of the fallout of an accident
  • Employees at centre of event: drug testing, hold out of service with pay, return "home" or head office
  • Formulate media statement
    • Give facts
    • Indicate that will investigate
  • Internal Communication
    • Responsible leader needs to be at the forefront
    • In writing need to instruct all employees not to make statements or speak to media about the issue – the spokesperson should represent the organization
  • Expressing empathy for what happened
  • Leader à visible
  • Do not lay/ take blame
  • Reassure public that you have it under control
  • Call appropriate authorities
    • Local authorities
    • Various jurisdictions
  • Remove employees from service until you can determine the cause.
  • Isolate the situation
  • Test/look at the other bags
  • quarantine all aspects related to the issue
  • non-confrontational
  • Engage the union at an early stage of the investigation
  • >Sideline< employees involved in incidents off the job –most certain take action
  • Stop procedures
  • Check internal protocol and or plan
  • Counselling for employees and victims family (now and also long term)
  • Establish who will responsible for investigation
  • Appoint or determine spokesperson for media
  • Initial investigation and short term action
  • Freeze site
  • Legal advice
  • Examine stock of medication
  • Redirect dialysis to other patients
  • Engage backup employees to take over the sideline people
  • Halt all treatment
  • Understand what happened.
  • Assess damages
  • Communicate once conduct investigation.
  • Demonstrate condolences
  • Statements about investigation, ownership. Social media, internet and external first before external comment to keep updated.
  • Look across
  • Management takes responsibility
  • Lockdown, risk management to continue treatment for others
  • Criminal or not, who to isolate, how far.
  • Lock down info training records, all details, working with officials
  • Face to face internal video conference.
  • Hospital Board involved and calling the shot
  • Tylenol case – tell everyone what they knew – tell everyone what they didn't know
Close to complete consensus of the group was specified on the following items:
  • Investigation into why
  • Communicate constantly, lay out a clear communication plan with expectations for timelines, process steps
  • Communicate the results of the investigation
  • Investigate to find root causes
    • Recreate what occurred Reviewing procedures to eliminate future occurrences
  • Initiating corrective actions, and explain to Minister and the public.
  • Communicate
  • Thorough investigation to all agencies involved to fully understand.
  • Regular updates to the media.
  • Non-punitive exercise
  • Provide progress report from CEO, health organization, regulatory body
  • Union will protect members
  • Develop plan for opening dialysis unit for getting patients back in
  • Reassure public of safety of hospital
    • News conference
    • Be honest with the facts
  • Don't cover it up
  • Don't fall into trap – don't assign fault or blame
  • No speculation
  • Just listen – talk – communicate, talk to staff – get information

Some consensus of the group was specified on the following items:

  • Consider: risk analysis regarding the particular operation ie the ICU process, the flight route, the aircraft, the ship/vessel (eg stop/continue/modify?)
  • As soon as aware, communicate with industry colleagues and organizations about potential problem.

Little consensus of the group was specified on the following items:

  • Consider discipline after the investigation. (table was really reluctant with this. They had to be prompted.)
  • Media updates planned periodically.

No consensus of the group was specified on the following items:

  • Share transparency – even if legal resistance - outcome
  • Set schedule of media briefing update
  • Becomes predictive
  • Ask how to organize ourselves
  • Warnings missed
  • See if anything unresolved
  • Seeing potential issues
  • Trying to figure out root causes (… find the holes in the swiss cheese)
  • Convene investigation
  • Procedural review
  • Pay attention to contributing factors
  • Review procedures along the supply chain
  • Encourage other people to come forward with other incidents
  • Start the information flow
  • Continue communications with your stakeholders
  • Clear communications plan (… who is going to say what)
  • Executive patience required
  • State the obvious that Safety is Priority One
  • Have to be genuine
  • Follow up with other health care facilities to share data … has this happened before … could it happen again
  • How do you encourage cooperation?
    • Follow process
    • Trust to determine what happened
  • Transparent, tell the truth, manage speculation
  • Take personal responsibility
  • Manage public expectations
  • (table was really reluctant with this. They had to be prompted.)
  • Consider corrective actions long term and implement corrective actions.
  • Arrange for counselling both for self and employees/families
  • Reach out to the families
  • Do risk assessment
  • Internal investigation, but may choose to have an external consultant to review findings
  • Advise public/press conference
    • Need to identify to public is this an isolated issue or is it a systemic issue
  • Communicate with legal department
  • Provide a report to governing body
  • If circumstances warrant à resign after the crisis
  • Leader takes accountability for the safety system
  • Notify the pharmaceutical company of the potential to confuse the drugs
  • Do a risk assessment – does this issue extend beyond the immediate?
  • Initiate and conduct investigation
  • Use investigation results to determine long term status of the employee
  • Action plan to avoid future incidents
  • Employees just before specifics (timing key)
  • Employees back to work after investigation, which employees – pharmacy administration
  • Follow back to work process – once determined role – when they are ready
  • Police investigation and follow behind
  • Reinforce just culture
  • Full legal counsel available
  • Union cooperation
  • Tools
  • Lessons learned crisis management plan changes
  • Implement additional / tighten protocols. Find gaps
  • Training (make sure they know what they are doing), additional training if something changed
  • Analyze the workload of the technician, the time of their shift
  • Share lessons learned with other authority
  • Research – happened before?
  • Employee counseling, for your own staff and for family members.
  •  Differentiate the boxes..
  • Reassuring staff and people that we are trying to get to the root of the problem and that we are taking appropriate action
  • Maybe there was a near miss? Making sure that everybody that was close to the case; working in the same unit, get proper training
  • Get people to talk, encourage them to speak

Appendix C: Output from Session 3

How do you find trouble before trouble finds you?

The purpose of this session was to identify best practices in proactive safety management. The session followed the panel discussion on the morning of the second day, which included presentations on the use of proactive safety data and processes.Footnote 5

Objective

To identify best practices in proactive safety management.

Process

  • Brainstorm on the following issue: "To help people get better at identifying and mitigating hazards without having incidents or accidents we need to ..."  
  • Identify main themes.
  • Select themes to report back to plenary.

Step 1: Brainstorm best practices for proactive safety management

In the first step, participants were asked to identify best practices in proactive safety management by completing the following statement: "To help people get better at identifying and mitigating hazards without having incidents or accidents, we need to...."

The ideas generated for all 8 breakout groups are presented below:

Step 2: Identify main themes

From the ideas generated in step 1, participants were asked to identify 1 or more key themes and summarize what the theme included. The main themes identified by all 8 groups are presented in the table below.

Table 7. Main themes in discussion on proactive safety management
Theme The focus of the ideas in this theme is…
  • Shared responsibility (everyone's job)
  • Culture (see something, say something; create reflexes; educate)
  • System including process (meetings); quality assurance (analysis, audit, continual improvement)
  • Balance of technology flow, people, and process
  • Optimize technology to drive information on process and people. When do you have/how do you maintain balance? Each helps manage the mix.
  • Voice and video
  • Smart use of…
  • Education and training
  • Risk awareness and involvement
  • Monitoring many sources of information
  • Trigger analysis of risk (small or big) and implant preventive measures: can be task based or organization wide
  • Robust safety management system
  • Data and information
  • Transparency and communication
  • Make information visible
  • Make that goal visible and tangible and set goal, make it real
  • Focus on the people at all levels
 
  • People
  • Processes
  • Technology
  • Empowering them to think about what if and why? Find solutions, part of the system.
  • SMS structure: improve better outcome
  • Continually improve system
  • Employee engagement
  • Health & safety committees
  • Data
  • Robust reporting
  • Mining
  • Sharing
  • Commitment
  • From everyone in the company that something needs to change; culture
  • Building trust
  • Vigilance
 
  • Education/training on advance safety principles
  • From health & safety committees
  • Investing in your people

Appendix D: Output from Session 4

Data sharing: How do we maximize use of voice/video to improve safety while balancing rights and obligations

The purpose of this session was to have a discussion on the use of voice and video data to improve safety, overcoming obstacles to the use of such data in a way that is respectful of rights and obligations. This session followed an update on the locomotive voice and video recording (LVVR) pilot study and a presentation by the TSB chief operating officer outlining the legal and other considerations in expanding the use of voice and video data.Footnote 6

Objective

Identify means to capitalize on opportunities and overcome obstacles in using video/voice recordings for safety purposes.

Process

  • Develop a list of likely uses: How would you make use of voice/video data to improve safety if they were available?
  • Determine proportion of group who would likely use data for this purpose.
  • Develop list of obstacles for the use of voice/video data.
  • Identify means to overcome most significant obstacle.
  • Repeat for other obstacles.
  • Identify points to report back to plenary.

Steps 1 and 2: Develop list of likely uses

In the first step, participants were asked to identify the anticipated application of voice and video data for safety purposes by answering the question "How would you make use of voice/video data to improve safety if they were available?"

Groups were also asked to identify the proportion of participants who could envisage using voice and video data for this purpose.

The output from all 8 groups for these 2 steps is below. All ideas are presented, and categorized by the degree of consensus of the group specified.

Close to complete consensus of the group was specified on the following items:

Some consensus of the group was specified on the following items:

No consensus of the group was specified on the following items:

Step 3: Brainstorm obstacles

In the third step, participants were asked to develop a list of obstacles to the use of voice and video data recording for safety purposes. The output for all 8 groups is below:

Step 4: Identify means to overcome obstacles

In the final step, participants were asked to select 1 or more of the most pressing obstacles identified in step 3 and identify possible means to overcome them.

Table 8. Overcoming obstacles to using of voice/video to improve safety
Obstacle Means to overcome
Suspicion by employees
  • Consultation; create memorandum of understanding; not admissible
  • Need guardian
  • Company policy
  • Check what other countries are doing
No interest
  • Show benefit
  • SMS follow-up (controller, operator)
  • Regulatory reform (consultation and feedback)
  • Show what other countries are doing
Lack of resources
  • Incentive program
  • Data on why it's worthwhile
Not specified
  • Revise the law
  • Think of other areas where this may collide/impact
  • Better understanding of legal parameters/limitations
  • What are we trying to solve and how does the law get us there?
  • Find out what police have been doing
Misalignment of stakeholders
  • For government, proceed with new regulations by mode to address modal differences
  • Establish clear protocols, just decision matrices within SMS
Privacy
  • Full discussion about expectations
Safety
  • Show the security benefit post-event or proactive process of using this data
  • Draw on experience of how the use of this data has benefited safety in other industries (e.g., trucking, aviation, banking)
One size fits all
  • Have different means and regulations for various types of operations (705, 703, etc.)
Distrust
  • If culture (safety) is appropriate (i.e., demonstrated that you don't take a punitive approach), employees would be less inclined to distrust appropriate use of recordings
  • Process needs to be evidence based and supported by risk assessment methodologies
  • Ensure all stakeholders are fairly consulted
  • Gradual implementation
Not specified
  • Data
  • Benchmarking
  • Other modes, ideas
  • Social recognition
  • Public safety supersedes privacy
  • Creates safer work environment; not distracted
  • Pre-existing protocols to protect
  • Establish to protect integrity of data
  • Policy on how equipment is used
  • Sharing lessons learned
  • Involve employees in policy development protocol and lessons learned
  • Legislation worded to clearly address obstacles
  • Tracking non-compliance/baseline
Mindset/Readiness of crew acceptance/Buy-in
  • Legal changes; framework needs to be in place; getting better protection on its use
  • Education: solving the questions of being concerned over use; or their fear of the unknown; change management; maybe different strategies for different age groups
  • Consistency in application
  • Limiting and clearly prescribing clear circumstances in which data cannot be accessed
  • "Iron-clad" protection
Human rights issue/employee
  • Sit down with employees and come up with agreed-upon parameter(s)
  • Set up sandbox to play in: engage employees
  • Get help from the TSB
  • Normalizing that the recorders exist
  • Need to sell the idea that recorders are important
  • Change the law
  • Accept that you can never address all the challenges
  • Incremental approach
Legislation
  • Slow regulatory process

Other observations noted during this session

The following points raised during this breakout session were outside the scope of the process used to guide the discussions: