Over many years I have seen alerts and investigation summaries distributed across organisations and industry with a view of sharing learnings that will hopefully prevent other similar incidents. Despite this occurring similar if not identical incidents continue to occur.
A major barrier to learning from incidents and unwanted events continues to be the context of the failure. It is human nature to take look at a scenario, and if you can’t relate to that scenario or its context as described in the alert and/or incident summary and/or it involves a piece of plant or equipment you do not use or an operating scenario you do not employ, it is quickly discounted as “not really relevant to me”.
The failure to look beyond the context of an incident underpins one of the reasons why companies continue to have repeat “unexpected” events. As an example of what I am saying, an incident occurred in which a particular piece of plant had modifications undertaken to allow it to operate in a rail environment. That piece of plant was involved in a serious incident as a result of the modification.
A detailed alert was sent out post incident which described the plant, what it was doing and the failure that occurred. When workplaces were engaged across the business to assess the effectiveness of the lessons learned and subsequent actions; the overwhelming response was that these lessons were seen as only relevant to similar projects to the one that had the incident, similar items of plant and/or similar operational scenarios.
Although the alert highlighted the failures, it did so within the context of the workplace in which the incident occurred. As a result, many people discounted the learnings as irrelevant to their workplace because they didn’t use the type of plant or the operational process that led to the incident.
When we remove or broaden the context of the scenario in which the failures occurred, overlay a broader operational context and ensure they are they are communicated in a way that more easily enables people to overlay their own scenarios over the failures, we start to see learning occur.
People responsible for communicating events and acting on alerts, interventions and investigation reports from other areas (internal and external) need to ensure that they extract the failures from the context of the incident in question and ensure that they are communicated in a way that allows people to more easily identify how these failures can occur within their operational context and ask themselves:
- Can these failures occur in my workplace?
- What are the current or future scenarios and activities that are in my workplace that can lead to these failures if not identified and managed effectively?
- Who needs to know about these and get involved, and what needs to be done?