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Learning from incidents

 

 

Many incidents occur because organisations tend to fail to learn from the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve this process, it is necessary to gain insight into the steps of the process and to identify factors that hinder learning (bottlenecks).

The learning from incidents process consists of a five steps. The quality of each step depends on the drivers, methods, resources and outputs. Each of the five steps leads to a result that is a vital input for the next stage in the learning process. Below the steps are further explained in detail.

Below, the steps are further explained in detail.

Step 1: Acquiring

As a first step, an overview of incidents is required. In order to facilitate the collection and registration of incidents, a reporting system should be in place. The following aspects are important to achieve a positive reporting culture:

  • Consider the possibility for employees to report anonymously;
  • Give feedback to the employee about what will happen to the filed report;
  • Do not punish who files the report, rather reward him;
  • Draw up decision criteria to determine which reports must be investigated in depth and which must be processed in another way.

Step 2: Investigation & analysis

The purpose of this step is to gain an understanding of the causes of an event. To achieve this, an incident investigation is required. This consists of three steps that can be taken iteratively: determining the scope of the investigation, collecting the facts associated with the incident and analyzing them. The following factors are important for a good investigation:

  • Provide independent researchers;
  • Invest in a good research method.

Step 3: Planning interventions

In step 3 it is important to draw up a realistic action plan of interventions in response to the incident investigation. The causes must be prioritized. Based on this, recommendations can be generated and elaborated in a concrete action plan. Consider the following:

  • Prevent improvements at an individual level. Instead, focus on the work environment or organisation. Not: “the employee should pay more attention”. But: “Redesign the interface of machine X so that it suits the task better”.
  • Identify what it takes to implement the recommendation: how much time, money, knowledge, materials are needed?
  • As an organisation, choices have to be made; implement the measures with the best safety effect / effort ratio.

Step 4: Intervening

It is necessary to communicate the action plan for creating common ground within an organization. Sharing the plan and its purpose ensures that the message is sent that safety plays an important role within the organization, making it a topic of conversation. Also pay attention to monitoring the progress of the actions. As time passes, attention to and perceived need of the plan can reduce. Suggestions:

  • Make 1 management function responsible for the development of the action plan;
  • Communicate clearly and unambiguously about the action plan as (line) management, mentioning relevance and need;
  • Draw up the action plan in a SMART way, with clearly defined role and function responsibilities.

Step 5: Evaluating

An important step for an effective learning from incidents is the evaluation of the taken actions and of the learning process. It must be evaluated whether or not the actions were carried out and to what extent they were effective. Is the risk or the cause of the incident now gone or sufficiently controlled? Moreover, the reason why an action was not implemented should also be discussed and evaluated. As an organization, in fact, it may also be possible to learn from those situations. This way actions, processes and the impact on the organization are brought to the surface.