(40o) Learning from More Than Incidents

Consider a distribution of events. There are “normal” or “expected” events, that are the majority of the events. There are also critical events in each of the “tails” of the distribution. Some are bad, even dire (at the very far of the left end) and some are great, even innovative (at the very far of the right end). These at the right side may, in fact, be promotive of good safety and hazard reduction. Most “learning” organizations will do root cause analysis of the events that are bad (in the left tail) and disseminate this information to their organization. However, is this really a true learning organization? We submit that a true learning organization also focus’ on the good behaviors that promote safety and reduce hazard, that is, focuses on the right side of the distribution, trying to increase the proportion of behaviors and events in that area. One key way to do this is to have a fuller feedback process in the redlining and procedure change management process. This presentation will show how this process can be used to causes both organizational and worker learning. For instance, if a worker submits a good redline suggestion, then the organization directly improves, and the worker also learns how to give good feedback and is rewarded for it. If the worker submits a redline that is not correct or feasible, when the organization provides immediate feedback regarding this (i.e., education) to the worker, this process and the “thankfulness” of the organization is rewarding to the work. Further, the organization learns about procedure and training gaps. Leveraging the procedure redline system is one what that organizations can broaden their learning to become a more robust learning organization.