Learning From Accidents?

Accidents - "errors", "mistakes", "omissions", "oversights", etc. - are opportunities to learn from and to take steps to make sure that the same or similar will not happen again.

Unfortunately accidents are not a preferred learning source as the outcome of an accident may be major or even catastrophic, to the individual, the organization or to society.  

Learning from accidents with relatively minor consequences, or no consequences at all, is a better way ... but you need to have a risk classification system to make them important. So that resources will be made available to investigate, analyze and take remedial actions. How many organizations have such a risk classification system? Do you? And do you have the knowledge and experience to use it effectively?

It is far better to learn from incidents, from the events that did not result in loss but could have, if the circumstances would have been different. For that, you also need a risk classification system, to assess what could have happened, just in case .....

By the way .... a risk classification system could also be used when evaluating deviations noted during inspections or behavior observations. If fact, the substandard acts or conditions observed could result in loss .... if the circumstances would have been different.

Learning from accidents - how?

Learning from unwanted events requires:

• Know what happened - register facts for communication and cause analysis
• Know why it happened - carry out cause analysis
• Know why the consequences were what they were - evaluate post event actions
• Know what to do - so it won't happen again
• Carry out remedial actions - make sure they will be done well and on time; assign responsibilities
• Let others know - communicate and report so they will learn as well 

You need to have a system as is described in the an accident investigation protocol. So you will get the accidents and incidents to learn from. Then you have to find out what happened and why. And, when looking for the reason why the accident happened, keep asking why? Till you have come at the basic or root causes.

Then when you have done that, you need to store relevant information so you can remember or retrieve if when necessary. You learn as an individual by storing the information in you own, private, memory and, hopefully you will remember in the future. And hopefully, you will tell your wife, your children, friends and others about your experience. So they can learn from you and - in return, you can learn from their mishaps.

An organization can "learn" by storing the information in a database so it can be retrieved at a future date .... if someone remembers to check the database. Better, the reasons why the accidents occurred should be translated into safe work methods, procedures and into the management system. It then becomes part of the organizations "memory" or, if you want "the way we work".

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