Monthly Archives: April 2014

Supporting a Safety Case with my*KNOW

A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe and that risks are kept as low as reasonably possible in safety-critical industries, such as construction, transport and petrochemicals.

According to The Health Foundation, an independent charity working to improve the quality of healthcare in the UK, the core of a safety case is typically a risk-based argument and corresponding evidence that:

• All risks associated with a particular system have been identified
• Appropriate risk controls have been put in place
• There are appropriate processes in place to monitor the effectiveness of the risk controls and the safety performance of the system on an ongoing basis

One industry where safety cases are crucial is the rail industry, where they are developed to assist in the prevention of major accidents, including fatalities, whether to staff, passengers or both.

Whilst railways in the UK are considered a safe mode of transports, and accidents remain rare – they do occur, and it’s something all rail companies take seriously, especially in relation to ‘People Risk’ and accidents that occur due to human error.

Government statistics on rail accidents and safety show that both passenger and workforce fatalities decreasing from 2001/02 to 2012/13 – with passenger fatalities down from 5 to 4 and workforce fatalities down from 5 to 2. However major injuries of passengers show a slight increase from 274 to 299, with workforce injuries down from 173 to 114.

Railway companies want to bring these numbers down as far as is possible and railway safety cases are helping to do this.

In the UK a new regulatory framework for railways was introduced in 2006 that stated that the following key elements of a railway safety case were:

• Details of the safety case ‘duty holder’ and a description of its operation
• Details of risk assessments, including methodology, results and the implementation of risk control measures
• Description of the health and safety management system and a demonstration of its effectiveness, including provisions for audit and review.
• Description of the technical specifications for plant and equipment.
• Description of the operational and maintenance procedures.
• Particulars of arrangements for records of training and competence of staff.
• Arrangements for cooperating with other railway bodies.
• Arrangements for incident investigation and emergency response, including evacuation of stations and trains.
• Safety case development plan

Cognisco’s my*KNOW competency management platform can play a key role in helping organisations meet the demands and challenges of a safety case. It provides evidence in the case of audit, the ability to roll-back to a point in time to evidence the “state” of an individual or group’s competency/legal status at any time. It also enables the compliant organisation to plan and manage their risk by identifying any gaps or requirements to ensure they stay in line.

We’re working with a number of leading rail companies that have adopted my*KNOW to ensure they can meet regulatory health and safety requirements and compliance, and support their safety cases. The platform ensures that performance assessments, appraisals and training and development programmes are all in one place.

By using my*KNOW rail companies are:

• Ensuring they can demonstrate compliance
• Adopting a best practice approach to auditing and reporting
• Reducing health and safety risks

my*KNOW can be used by any safety-critical industry to ensure they comply to stringent rules and regulations specific to the sector and meet the requirements set by their safety case framework.

Ignoring the customer has cost the banking sector greatly

At one time many years ago people were on first name terms with their bank manager and the customer was king. Over the years the banking sector has tried to distance itself from the customer by providing technology such as ATM’s, telephone and online banking. The results have seen many banks branches closing on UK high streets, customers not having direct contact with banks and the customer relationship thrown into jeopardy.

Chris Skinner from the Financial Services Club blog has much to say on the subject. In a recent blog post he highlighted how the fact the banking sector’s lack of customer focus is back firing. He says “Now the banks are concerned about customer defection because customers are so comfortable doing it for themselves they are now using technology to by-pass and avoid dealing with the bank completely.”

He added, “This one will not be solved until banks realise that the technology has put the customer in control and all the customer wants is a fault-free, seamless, intuitive capability to manage their money.”

Many people no longer have any allegiance to a particular bank and all they require is a somewhere to put their money. With competition in the market heating up, banks distance themselves from customers at their own peril.

It used to be that people stayed with a bank for life, but not anymore Last year, the 7-day switching service was launched making it easier for people to switch bank accounts. This was part of Government reforms to improve Britain’s banking service and improve competition between banks. Low levels of switching in the UK current account market the Government said was a major barrier to competition between banks and better services for customers.

Some banks are already taking the lead in improving customer services. A recent survey from revealed Britain’s best and worst banks for customer service. They polled close to 9,000 people and First Direct came out top of the poll as Britain’s most popular bank amongst customers.

92 per cent of First Direct’s customers rated its customer service as “great”. Internet and phone-based First Direct has topped the website’s survey every year since their polling began in 2008. The bank’s policies, which include £100 bonuses for people that open new 1st Accounts, have contributed to its popularity with customers.

Second choice was Spanish bank; Santander with 74 per cent of customer’s reporting its service to be “great”, with other top performers including Co-op, Nationwide and Halifax. On the flip side TSB was revealed as the UK’s worst bank for customer service, with just 37 per cent of the bank’s customers rating its service as “great”, and 20 per cent rating its service as poor.

Part of improving customer service in banking is having a clear understanding of how customers are treated by staff at every interaction, through every channel – whether that is on the phone, face to face, online or through social media. Banks need to ensure their people are not only competent but demonstrate the right behaviours all the time.

Banks need to strive for customer service excellence and look at a behaviour change where needed. With most people’s main contact with their bank over the telephone or Internet, a bank’s customer service team needs to be at the top of its game. The banks that invest most in customer service will be the winners in the future.



Could the NHS take the same approach towards Human Factors & Behaviour Change as the Airline industry?

According to Martin Bromiley, the founder and director of the Clinical Human Factors Group , the NHS is starting to recognise the value of addressing “human factors” to improve safety, but progress is not happening quickly enough and valuable lessons could be learnt from the airline industry.

Martin set up the Clinical Human Factors Group following the death of his wife. She had gone into hospital for a routine sinus operation in 2007, but died 13-days later following complications during the operation. The inquest revealed a series of “human factors” or failings in “non-technical skills” were responsible, despite the medical team having many years’ experience between them.

What has this to do with the airline industry? Well Martin is an airline pilot and knows that human factors are the cause of 75% of all aviation accidents.

His experience working in the aviation industry and how it deals with human factors in relation to attitude and procedures, led him to set up the Clinical Human Factors Group to help transfer some of this learning to the NHS. Whilst the airline industry knows that human error is the cause of the majority of airline accidents, in the medical profession this is not quantified.

It’s only recently that the NHS is starting to look at human factors as a way of improving standards. According to the Royal College of Nursing “human factors’ refers to a theory of the relationship between human behaviour, system design and safety that is becoming increasingly influential in helping us understand the causation of errors, accidents and failures in health care systems. An understanding of the core elements of human factors theory will enable you to improve the safety and effectiveness of your own practice.

Martin highlighted four key attributes of the aviation industry which could offer the NHS food for thought. The first is that safety is a pilot’s priority. He points out that in theory the same should be said about the NHS, however, he is often told that medical professionals have a lot of competing priorities such as targets and budgets, to which he says that pilots have the same priorities. However, if there is ever a conflict between target and safety, safety is always the priority for pilots.

Secondly, all major aviation incidents and accidents are investigated by external whose only brief is to learn what happened and disseminate learning. The focus is not on blame – this is left for the judicial system or airline disciplinary process once the investigation is complete. UK airlines have a policy of immunity from disciplinary action in the event of inadvertent human error freely reported – a policy that puts learning about safety first.

Thirdly, he says from the mid-1940s onwards the aviation industry started to understand there were enormous benefits from designing aeroplanes around the needs of humans. However, by the 1970s it became obvious that safety improvements gained through design and technology were no longer reducing accident rates and a giant leap could only be made if we could understand that 75% of accidents are caused by “human factors”.

The fourth thing he highlights is that all pilots, air traffic controllers, cabin crew and engineers have to understand human factors as part of their training. They have been re-skilled, to understand threats to safety, ways to avoid, trap and mitigate error, the skills involved in teamwork, and communication and leadership in a safety critical industry.

So what can the NHS learn from the aviation industry? Mirroring the industry’s transparent approach to investigating accidents, discussing human factors and learning from mistakes rather than looking at blame could go a long way toward changing the culture of the NHS and ensuring patient safety comes first.


How can Britain’s workplace safety record be improved further?


Provisional figures from the Health and Safety Executive (HSE) released in October show a significant drop in the number of employees killed or seriously injured in the past year.

An 11 per cent drop in major injuries is reported compared with 2011/12, and the number of people killed at work fell to 148 in 2012/13 from 171 in the previous year. All of which shows an improving trend, but does it tell us the full story?

The study found that 19,707 major injuries such as amputations, fractures and burns were reported in 2012/13 compared with 22,094 in 2011/12. This is the lowest number of work-related injuries since records began in 1995. These improved figures can be attributed to the commitment from Britain’s workplaces to improving safety for their employees, according to HSE employees, according to HSE chair Judith Hackitt.


But in spite of this good news, major and minor incidents and accidents are still happening too frequently.

An estimated three million working days are lost annually due to injuries at work, with slips and trips making up more than half of all reported injuries.

So how do we correct “unsafe” behaviour? We all know that health and safety in the workplace is paramount, especially in industries such as transport where the potential dangers are great. But it is still a challenge for companies to get it right. A cross-industry International Data Corporation (IDC) report, Counting the Cost of Employee Misunderstanding, reveals that one in four employees do not understand certain aspects of their job role. Major knowledge gaps remain unaddressed in many organisations. This is in spite of investment in training.


Human behaviour is often a contributory factor to injuries. Employees misunderstanding their roles or making critical mistakes at work can not only result in injuries and absenteeism, but also in millions of pounds worth of legal damages and even loss of life.

In industries where health and safety is a big concern, providing employees with situational judgement assessments that correlate understanding and confidence can help to prevent injury and even death.

At Cognisco we work with many leading rail companies in the UK and overseas to ensure their staff are competent and safe when performing their roles. All rail companies today are required to have formal competence management systems in place to maintain and assess the competence of operators carrying out safety-critical work.


At network rail, for example, we have introduced a formal management system to assess the competence of over 10,500 operators responsible for safety-critical work.

Britain’s workplaces could be far safer places if more companies revised their training and assessment programmes to improve the competence and confidence of their employees.

With regular situational judgement assessments to map employee competence, confidence, engagement and behaviour, companies find out what their staff truly know, how they work and the decisions they make on the job. This knowledge could be the key to preventing errors and misunderstanding that could lead to incidence and injuries.

There is a need to develop a long-term safety culture strategy; recognising that most accidents are caused by unsafe acts, and that influencing staff behaviour and attitudes is the way to reduce accidents further.