‘Black Box’ Thinking for Policing

Introducing Force-Wide Notable Incident Procedures

In Matthew Syed’s great book, Black Box Thinking, he identifies that both airlines and medical systems have well-honed procedures which allow the identification of potential safety issues and the distribution of lessons identified quickly to encourage rapid organisational learning.

My own force C3 Division has successfully introduced a really good system which is similar called a Notable Incident Process. The goal of this process is:

‘To promote an improvement culture where staff are encouraged to report adverse incidents or ‘near misses’ and introduce processes as soon as possible where these can be recorded, assessed and any improvement identified and implemented’.

This is an excellent idea, well executed. It removes the traditional blame culture ethos and ensures staff can be confident that if there are issues then they can raise them and have them acted on for the benefit of all. It’s early days for this in my force and I am sure there will be challenges, but it looks really promising.

Whilst we all have ‘near miss’ procedures in our own organisations I am not sure we are really making the best of what we could when incidents occur. Near misses are recorded inconsistently, if at all and there is little rapid sharing of information to ensure wider organisational learning.

Perhaps it’s time to roll this sort of scheme out force wide for all incidents? I could see a simplified system working as follows:

· An online portal form to allow for rapid information capture across the force.

· A daily review to assess / edit and approve dissemination of Notable Incidents that come in.

· A push email linking each notable incident to frontline supervisors in the relevant work area to ensure the learning is disseminated in a timely fashion and reaches the attention of the right people in the right timescale so they can brief their teams.

Of course there are a couple of pitfalls. We have already seen elements of the Scottish media use the Notable Report Process to try and trash the excellent work of C3 Division in this area. Frankly the quality of journalism surrounding this has been lazy and sensationalist and it requires (as we have seen from the SMT in this area) a robust force level response and the staff to be directly reassured that they are doing the right thing reporting.

It also requires some leaders to reassess their attitude towards errors in the work place and approach these with a less punitive outlook. The system falls at the first hurdle if the leaders within the job don’t get that reporting and subsequent learning is more important in making sure someone is ‘held responsible’. This direction of travel needs to come from the very top.

Finally it requires a relationship with our Police Investigations &  Review Commissioner (PIRC) that endorses and understands what the intention of the force is. This may be the toughest nut to crack. You’d like to think however that this is somehing that the PIRC would encourage and actively support. 

Aspiring to generate fast learning across the Force has to be a no-brainer. We can use the example of our own C3 Division as a model for the rest of us to continually get better at the job.

We take millions of calls a year and make tens of millions of decisions around those calls on top of that. By and large we get them right. But when we don’t a Notable Incident Process gives us a valuable opportunity to identify issues and trends from these calls & improve how we look after both the public and ourselves. 

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Author: West Coast Response

I'm a Police Sergeant here on the West Coast of Scotland. I love the job and the folk that do it. I enjoy polite debate on policing and criminal justice and am particularly interested in the practical impact of policing policy, police leadership & making the job better for frontline officers.

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