(152a) Systematic Approach to Improve Learning from Incidents

Learning from incidents has always been very challenging for industry and regulators due to the associated complexity in human and organizational behavior. In spite of the efforts and resources spent on incident investigation processes and organizational learning techniques, the outcome has not shown a significant improvement. Chemical process incidents such as Texas City Refinery explosion, T2 Laboratories explosion, and West Fertilizer explosion continue to occur. It is evident that as an industry we are failing to learn from past incidents. The question is if we are ready to learn, are we following the right learning approach? Companies should adopt a systematic learning approach where the collected knowledge is leveraged in order to enhance safety management systems and consequently prevent future incidents. The objective of this research is set to enhance our understanding on how a company and the industry as a whole learn from past incidents and define the key elements to improve the systematic learning. The limitations in the learning system are identified and a framework is developed for improving the internal learning process and transferring knowledge within the company. Finally, a proposed incident investigation process will be validated through a case study.