(154a) Are We Really Learning from Incidents? a Discussion of Best Practices and Common Mistakes

I sent the safety alert last month, and another similar incident just happened!! Why don't we really learn from a safety incident?

Upon completion attendees will be able to:

- Understand the difference between learning and sharing incidents

- Understand ways to prioritize what gets shared Tips for communicating incidents

- What it takes to learn from incidents Overcoming asset owner pride Making it sustainable

Abstract: Typical issues encountered by organizations while implementing LFIs

- Trying to learn from everything vs. a focused, risk based prioritization approach

- Ambiguity to whom investigation outcomes and lessons learned are applicable:

- Encountering organizational barriers to learning (e.g., culture, structure, roles, etc.)

- Ineffective and/or inactive leadership drive and engagement

- Focus on compliance vs. commitment

- Misalignment of what is said vs. the what actually happens in the field (the ‘Say-Do’ gap)

- Overcomplicated and ineffective safety communication

- Inability to identify the true root causes

- Lack of systems to properly capture and disseminate lessons

- Lessons fail to result in revised documentation of standards and procedures for proper re-use

This session will focus on how to achieve the benefits of successful learning:

Reduce Risk - Lower overall organizational risk tolerance and incident rate

- Effective performance management systems and continuous improvement processes

- Active audit programs, identified safety barriers and robust safety-critical activities

- Prompt investigation of issues with focus on determining the true root cause

- Immediate, underlying and latent cause (s), including human/behavioral factors Committed Leadership & Organization

- Leaders demonstrate a commitment to safety and learning in their decisions and behaviors - Clearly defined basis from which to learn as well

as roles/accountabilities Impactful Knowledge Management

- Effective safety communication - Simple, memorable and visual communication - Effective systems for capturing, codifying, storing and retrieving