Learning from Incidents ( Learning Lessons from Accidents ) (Lesson Learning)

What is Learning from Incidents?

Actions have been taken as a result of the incident, which and that published internally as “lessons learnt”. (e.g. LFI –Learning from Incident )

It shows company commitment to improving.
It allows improvements to be made.
Reduce the number of incidents

LFI process model

Learning from incidents, or LFI, is just one of many activities in managing safety in an organisation.

LFI is defined as “a process through which employees and the organisation as a whole seek to understand any negative safety events that have taken place to prevent similar future events.”

The outcome usually should lead to changes in behaviour or technical process in any organisation if all stages of LFI are properly implemented.

The LFI framework

What are the importance of the Beneficial Events?

Near-miss offer free lessons.

e.g. Omissions- leaving something necessary out ( e.g. machine did not switched off after job completion)

e.g. Extraneous activity - doing something extra within a task, which is harmful (e.g. tightening a screw which is not easy to unscrew)

During Lesson learning, What Organisations need to ask:

What is essential to securing the H&S of the workforce today?
What cannot be left until another day?
How high is the risk to employees if this risk control measure is not implemented immediately?’

Why Lesson need to be learnt from adverse event ?

(Refer : www.hse.gov.uk)

Because Learning lessons involves acting upon:

Findings of accident investigations of any accident / incidents e.g. near-miss reports
Organisational vulnerabilities identified during monitoring, audit and review processes.
Even in well-designed and well-developed management arrangements there is still the challenge of ensuring that all requirements are complied with consistently.
After an accident or case of ill health, many organisations find they already had systems, rules, procedures or instructions that would have prevented the event but were not complied with.
The underlying causes often lie in arrangements which are designed without taking proper account of human factors ( , or where inappropriate actions are condoned implicitly or explicitly by management action or neglect.

Key actions in learning lessons effectively (from HSE.gov.uk)

Role of Leaders and managers

Show by your actions that safety is a core value
Promote a questioning attitude. Make sure you are not only receiving ‘filtered good news’ - do you welcome feedback and constructive challenge?
Resolve ineffective procedures that result in ‘workarounds’ or violations of procedures
Be clear about your organisation’s risk profile
Make sure your workers understand the risks that are being controlled
Avoid complacency - take responsibility for keeping your own knowledge and capability up to date

Worker consultation and involvement

Discuss plans with workers or their representatives
Avoid overburdening workers with initiatives
Involve workers in organisational change

Competence

Ensure that those providing top-level scrutiny have sufficient expertise to judge the importance of emerging health and safety issues and integrate those with other business decisions
Contractors must be competent and there should be checks in place to ensure they remain so Take steps to avoid the loss of corporate memory

What lessons need to be learnt from adverse events?

(lessons learnt)

When incidents occur they raise awareness and understanding of things that went wrong, and perhaps can go wrong again.
Learning helps about the causes of accidents( sequence of events) and near-misses that have already happened in order to prevent reoccurrence.
Experiences of previous incidents are translated into preventive measures, time.
Organization can prevent incidents in the future and the need for repressive actions at that time.

Why/What lesson should be learnt?

Objective of lesson Learning

Helps in reducing the number of accidents / incidents
To avoid corporate memory loss
Organisational vulnerabilities identified
To prevent unforeseen events
Helps to met the compliance of well-developed management arrangements, systems, rules, procedures or instructions or not
Helps to Identify Root cause
Help to identify the underlying causes with management (cause of accident)
Helps to identify human factors / failures ( skilled / unskilled)
Helps to raise awareness what went wrong
Helps to raise awareness what went right
Helps to understanding of things
To prevent un-intented consequences
Provide information that can be quickly acted upon
Helps to identify the hazard to avoid reoccurrence/
(it helps to prevent repeat of accident) / Helps to prevent reoccurrence
To determine the cause of incidents
To determine the root cause of incidents
To determine the immediate cause of incidents
To determine the underlying cause of incidents
Allow preventative actions before the hazard manifests ( It helps to identify the preventive measures, time.)
Identify future requirement(Control measure) and the need for repressive actions at that time
comparison with the own situation & systems .
Helps to generate creative solutions & take time to prioritize the measures.
Helps to assess that organization getting better or worse to control the accident.
To determine management system failure
To Improve or influence constructive problem-solving
To improve human behaviour by providing adequate training
Allow for continuous improvement
Helps to measure what might go wrong and why again
To disseminate the H&S information to others
To improve the H&S Culture
Identify weaknesses through Lesson learning.
(it helps to improve) Change/review to safety programs
(it helps to improve) Change to Policy , procedures, system & rules
Need for more effective supervision , more number of inspection & Audit.
Increase system credibility.
Able to implement best practices.
Identify the training need
(it helps to improve)-- Change to equipment design
Measure the effectiveness of control systems

How to be a learning organisation:

Your health and safety approach will take time, and you have to give your managers and workers the knowledge and skills to grow with it.
Find out what other construction companies are doing to improve their health and safety. Network with your local trade association or find out the latest from the Major Contractors Group (MCG).
Get ideas from how other industry sectors have improved their health and safety.
Walk and talk. Go on site and see what is going on. Ask what your workers really think about their safety briefings or toolbox talks.
Analyze near misses and worker feedback/suggestions to improve site health and safety performance.
Investigate incidents, accidents, and/or ill-health cases to find out the true cause.
Give your managers and supervisors health and safety objectives (e.g., how many observations should they do each week, how many toolbox talks should be delivered). Do not forget to periodically review these with them.
Encourage a no-blame atmosphere on site. Make sure workers are not always blamed for things that go wrong; recognize that it could be your decisions that are the cause.
Carry out the Health and Safety Diagnostic Tool (HSDT) or staff surveys every 6-12 months and use the results to learn and improve.
You can always call in consultants or occupational health experts to help you with difficult problems, and if you are not sure what to ask of them, a good starting point is to be really clear about what you expect the end result to tell you. As with any service, quality can vary, so shop around, ask for references and if in doubt, check the HSE website or your trade association for advice.
Communicate the lessons learned to the whole workforce. This includes accidents, incidents and ill-health cases, learning from other companies, post project reviews, etc.

As a worker what I can I do to be part of a learning organisation?

Share good health and safety practices with your workmates.
Don’t be afraid to make suggestions.
Get involved in any discussions during safety briefings and toolbox talks. People learn from mistakes so even stories about when things go wrong can be very useful.
Your site supervisor’s job is to keep you safe.
Help them do their job properly.
If you see something unsafe, report it. It’s often the simplest things that get overlooked and do the most damage.
If you nearly have an accident make sure you report it. It could be one of your work mates next time and they might not be so lucky.

Barriers to learning from failure

Accidents and incidents often arouse powerful emotions, particularly where they have resulted in death or serious injury.
On the positive side, this means everyone's attention can be focused on improving prevention.
On the negative side, however, the same emotions can also cause organisations and individuals to become highly defensive.
This is natural and understandable but needs to be addressed positively if a culture of openness and confidence is to be engendered to support a mature approach to learning from accidents and incidents.
All too often, in the wake of an accident, the tendency is to seek to attribute blame (frequently to blame the victim) rather than to search for root causes.
Yet arguably, the most important thing to establish about accidents is not just how they happened but why they were not prevented. Because ultimately everyone at work has some degree of responsibility for health and safety, a totally "blame free" approach may not be realistic.
Nevertheless, organisations should endeavour to create fair and just cultures in which individuals are not blamed for organisational safety failures over which they have had no control.

Ineffectiveness of remedial actions could be due various reasons: Implemented actions ineffective due to a lack of resources (money, time, people) or causes other unforeseen risks or no tracking and follow-up actions are in place

Lack of prioritisation of actions or no action defined, responsible person was not assigned
No one checked the proposed remedial actions, people fear proposing actions like a change in design, due to fear of top management
Easier actions implemented but more complex actions left unattended for a long time
Only a quick fix approach is used and root causes of incidents are either never addressed or delay time on decision for remedial actions
Remedial actions were either not meaningful or inappropriate to the level of risks or nature of incident
Remedial actions were unrealistic or overall recommendations are not SMART (specific, measureable, achievable, realistic, time bounded)
Lack of management commitment for implementation and follow up or cultural issues in organisation
Defective incident investigation methodology lead to improper proposed actions
Competency questioned in relation to incident investigation, outsourced experts or competency required in devising remedial actions
Resistance to changes or other existing organisation priorities for implementation of remedial actions
Action is not closed out due to individual risk perception