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All incidents and concerns that have or could affect safety should be reported, recorded and analysed. This is done to enable learning and to help stop these things happening again. All learning should be acted on.

Your incident reporting system needs to be used. Induction and on-going training are vital, but are only a part of ensuring that this happens. Your system should be openly and regularly used, particularly by senior staff, to have any chance of success. For all but the most serious or repeated errors, avoid penalising people for incident reporting. 

What to Report

To help create good safety reporting in your operation, your team needs to be very clear on what they should report i.e. there should be clear reporting triggers. This needs to include all incidents i.e. events that could have or did result in a loss, harm, or death, and should also cover:

  • Any safety observations that could improve your safety systems
  • Anything else that you and your team decide is important to capture

How to Report

Design a reporting system that works for you and your operation. It should include:

  • An environment where everyone feels ’safe’ in reporting things that aren’t right
  • Clear responsibilities e.g. who files the report, who receives it and who follows up on it
  • Timeframes for when a report must be filed after the event has occurred
  • Criteria and timeframes for when a report must also be made to an external agency e.g. Department of Labour, Maritime New Zealand or police
  • Simple processes – simplicity is crucial to encourage people to report
  • Standardised reporting forms. Although most operators use one form for all, you may choose to use different forms/methods for different events or incident severities

Learning and Following Up

Every incident is an opportunity to learn. Reports must be analysed to find the actual and/or potential cause(s) and, where necessary, each of these must have a follow-up action to stop it happening again.   In order to realise this it is important that:

"When we set up our reporting system, no one used it. A whole lot of things have eventually made it work – simplicity, training, persistence – but possibly the most important has been our commitment to follow-up on each report. Even now though, we need to keep pushing and leading by example to keep the reports coming in..."

  • All incidents ( including near misses) are reported
  • Management and senior staff  lead by example i.e. openly use and support good incident reporting and ensure recommended follow-up actions occur
  • Someone is responsible for the learning and follow-up process
  • Report analysis involves the right people. Analysis of specific incidents may involve team members with specialist technical skills, or an independent expert
  • A process exists for deciding and recording what follow-up actions, if any, are required
  • There are timeframes for analysing reports and for actioning any recommendations made
  • Follow-up action is completed, recorded and monitored for effectiveness
  • A clear process is established and used for sharing learning with all staff and other interested parties e.g. other operators and your industry associations
  • Incident records are reviewed to identify trends and make improvements as necessary e.g. end of season incident report reviews
  • You consider using a central database to help enable a wider understanding of incidents and to compare your incident occurrences with those of the wider sector, e.g. National Incident Database ( NID)


Training and Monitoring

Training and monitoring should include:

  • Learning from past incidents. This helps to reinforce why a particular safety procedure is in place
  • Reinforcing the importance of incident reporting
  • Checking the number of incidents being reported. Nil or low reporting does not usually mean there are no incidents or concerns

Record Keeping

The records of your incident management processes are important not just for you, but for any external checks. They should include:

"I want to  prevent incidents and that means learning from near misses – there’s nothing worse than hearing after an incident that some (or all) of our team ‘saw that one coming"

  • Copies of all completed incident report forms and your accident register if you choose to use one
  • Minutes from any incident review meetings, including participants’ names
  • Action and learning points resulting from incident reviews, and details on when and how they were followed up
  • Information on your use of any external incident analysis process e.g. National Incident Database ( NID)