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Gbegsy  
#1 Posted : 18 January 2017 11:50:39(UTC)
Rank: New forum user
Gbegsy

Has anyone seen or used a really effective process/system for identifying, capturing and embedding lessons learnt from an incident investigation?

peter gotch  
#2 Posted : 18 January 2017 14:04:32(UTC)
Rank: Super forum user
peter gotch

Gbegsy

My preferred process is 5Ys.

thanks 1 user thanked peter gotch for this useful post.
Gbegsy on 09/02/2017(UTC)
johnwatt  
#3 Posted : 18 January 2017 14:09:19(UTC)
Rank: Forum user
johnwatt

Originally Posted by: Gbegsy Go to Quoted Post

Has anyone seen or used a really effective process/system for identifying, capturing and embedding lessons learnt from an incident investigation?

Check out HSG 245, lots of useful guidance.  "5 Why's" is a useful tool but perhaps not the best one (in isolation) for incident/accident investigation. 

http://www.hse.gov.uk/pubns/hsg245.pdf

Edited by user 18 January 2017 14:10:00(UTC)  | Reason: typo and citation

thanks 2 users thanked johnwatt for this useful post.
acetylene on 28/01/2017(UTC), Gbegsy on 09/02/2017(UTC)
Kate  
#4 Posted : 18 January 2017 14:30:54(UTC)
Rank: Super forum user
Kate

I don't think anyone has.  Perhaps one of the things we learn from major industrial accidents is that industry doesn't learn from past accidents.

johnwatt  
#5 Posted : 18 January 2017 14:44:58(UTC)
Rank: Forum user
johnwatt

Originally Posted by: Kate Go to Quoted Post

I don't think anyone has.  Perhaps one of the things we learn from major industrial accidents is that industry doesn't learn from past accidents.

I wouldn't say that's strictly true. The UK has one of the best health and safety records in the world. There is considerable effort to to fully investigate accidents and understand their causes allowing us to prevent reoccurances in the future. That's not to say that we always get it right but it would be unfair to say that we never do full stop. 

HSG 48 is another interesting read from that perspective.

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Gbegsy on 09/02/2017(UTC)
sadlass  
#6 Posted : 19 January 2017 12:32:20(UTC)
Rank: Forum user
sadlass

Using incidents for learning - hmm. Not sure 'a process' is the right tool.

Who is the learning intended for? Lessons for managers or workers or both? How to deliver will depend on the audience, and the points being made.

Don't have a process for it, but have used in-house incident learning - usually close-call events rather than injuries, or sufficiently distant in memory to be less personal (see next point).

Using your own company incidents for learning has the problem of in-built delay if there could be any legal action pending, or confidentiality around individuals who, whilst unnamed, are likely to be identifiable by the workforce. Individuals may of course, be willing for their own mishap to be promoted widely as a case study, but not always. People involved may include managers.

Any incident can be used as a case study for learning - doesn't have to be your own (in most organisations they are fortunately a long time coming). Many, if not most, incidents do not have any real learning points, although I do see efforts (by safety folk) to try to make them, resulting in pointless 'take more care' messages.

So - what is it you want to do? Educate people - in which case any relevant case study can be used.

Or find the right way to tell the story of a real in-house mishap with clear lessons for the future in the hope that it being 'one of our own' makes for a stickier message, demonstrates follow-up by management, and allows (as they say) closure.

 

thanks 1 user thanked sadlass for this useful post.
Gbegsy on 09/02/2017(UTC)
RayRapp  
#7 Posted : 20 January 2017 08:31:50(UTC)
Rank: Super forum user
RayRapp

'Lesons will be learnt...' I wish I had a pound for every time I have heard that statement - I could have retired by now!

The reality is that lessons are often not learnt. One of the problems with this concept is that causal factors are often very diverse and complex. The other reason being that memories fade and vigilance wanes. As Reason states: 'Organisations get the repeated accidents they deserve'.

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