The Weekly Reflektion 19/2022

Repeated incidents show that we are often not effective at learning lessons and preventing recurrence. People can be seriously injured or die from this failure.

Learning lessons demands organisational stamina to follow the process to the end. How is the stamina in your organisation?

Several of our Reflektions recently have addressed the quality of investigations and the poor identification of causes leading to challenges with making changes that would prevent recurrence. We have also highlighted the importance of learning from success. In Reflekt we use a high-level model to describe the processes concerned in learning from incidents, from accidents or from successes. This can be summarized as analysis followed by dialogue, reflection and finally change.

Firstly, a good investigation is critical in identifying the causes. Once the causes have been analyzed the people involved need to get together with the investigation team to discuss the findings, ensure the findings reflect the real situation on the ground and are a good basis for making improvements. It is not unusual that the investigation team have misunderstood the situation and come to conclusions that are unhelpful to promoting learning from an event. Benjamin Franklin is reputed to have said “Tell me and I forget, teach me and I may remember, involve me and I will learn.” Involving the people who are working every day with the tasks is a good start to verifying findings and identifying realistic actions. This dialogue should take place before the final investigation report is released.

Buy-in from management is important. It is the management who create the culture for performing investigations, for people to cooperate and be honest in these investigations, and who are also responsible for prioritizing resources. These resources should be available both when an incident has occurred and needs to be investigated, and when actions are identified, executed, and implemented.

 When something has gone wrong, one of the most important aspects of the learning process is that something should change. Given such an incident, if we continue do what we always have done, then we will get what we always got. Changes may be technical for example in the equipment used, a procedural change, a change in training, or a change in behaviour. These changes of course need to be implemented. This might be training in a new procedure, or a change in the requirements in the management system, which will have to be introduced to the users. It may be a change to the maintenance system for new equipment or updating of the drawings for the facility. Finally, a verification of some form is necessary to confirm that the measures have had the desired effect.

Jop Groeneweg from the University I Leiden, Netherlands studied 11 companies to assess how effective their processes for learning were. He divided the process into 5 parts;

His findings showed a relatively effective start with the reporting and registration of events, with progressively less and less effective investigation and analysis, planning interventions, and intervening phases. Evaluating the effect of the measures taken was generally ignored.

Does your organisation have the stamina to complete this learning process or do your efforts fizzle out before implementation is complete?

Reflekt AS