The Weekly Reflektion Week 25 / 2020
Reflekt was started in October 2017 and our focus was to use the insight from investigations into Major Accidents to learn and hence prevent future Major Accidents. We also believed that these insights would provide learning to improve performance in other areas. Reflekt has organized seminars and lunch and learns, facilitated workshops, and carried out studies and analyses. We have also developed tools and methodologies for helping organizations with Major Accident prevention. Since October 2017 we have published 137 weekly Reflektions that hopefully have given some guidance and even inspiration on Major Accident prevention. Two and a half years into our quest and it is time for some reflection over what we have learned and how to progress.
Reflekt supports the Petroleum Safety Authority main theme for 2020 ‘Never another Major Accident’. 2020 being the 40th anniversary of the Alexander Kielland disaster. How does learning from Major Accident contribute to prevention of Major Accidents? How should we focus on learning from Major Accidents when we already know that we struggle to learn from our own incidents?
In 2019 the Norwegian government published a white paper on HSE in the Petroleum industry. The white paper was in turn based on a report from a cross-industry working group that identified several areas where the industry needed to improve. One of these was learning from incidents and accidents and experience transfer of the learning throughout the industry. Echo’s of the learning from Major Accidents that Reflekt tries to promote.
It is difficult to dispute the need for learning and the responsibility of management to facilitate and encourage learning. It is obvious from the recurrence of incidents and accidents that this is not easy, despite significant efforts from the industry. Anyone that has tried to facilitate learning from incidents and accidents will appreciate the challenges involved. Even companies with a real interest in learning and those with learning processes in place still experience recurrence of incidents.
Reflecting over our experience in learning from Major Accidents there is one factor that is particularly important for effective learning and that is ‘relevance’. The people in an organisation may find the learning from Major Accidents interesting but this interest may be of ‘academic’ value. Unless the people see the relevance to their organisation, their circumstances, and their culture they are unlikely to see the benefits in following up this learning. Without ‘relevance’ they are unlikely to follow up and prioritise any measures from the Major Accident.
So, how do we find out what is ‘relevant’ for any organisation? We need to capture signals that are being sent by the organisation. Signals can be from incidents and accidents that are occurring assuming these are investigated in a systematic and sympathetic manner. Signals can also be from successes that are being made if we try to understand why these successes happen. What people are talking about, are excited about, are frustrated over and are uncertain about are all signals that can be captured if we are willing to talk to people in the organisation. There are good signals, bad signals, strong signals, and weak signals and these need to be collated and processed to create a coherent picture of the challenges and the successes in the organisation. Once the signals are processed then ‘relevant’ learning from Major Accidents and other appropriate incidents can be used to facilitate learning. This should be done by creating narratives that can be used to stimulate dialog within the organisation.
Reflekt will continue to promote learning from Major Accidents and hopefully make our contribution to improvement in the prevention of Major Accidents. However, if you look for and understand your signals and can find relevant Major Accidents to help you create a narrative that your organisation is likely to respond positively too, then you can really make a difference. Are you looking for signals?