Learning from Incidents
By Edward Smith
It is a common experience to hear the phrase “We must learn lessons from this” following a major accident, or a more everyday event such as losing in a sporting competition. Indeed this has become such a common phrase that one may feel that learning lessons is an automatic or natural process. In fact the evidence from accidents and incidents indicates that it can be difficult for major hazard industries to learn effectively from such events.
Previous research has indicated challenges at several stages in the Learning from Incidents (LFI) process including:
- Reluctance to report incidents due to fear of disciplinary action or the perception that reporting does not lead to any change
- Lack of appropriate expertise in the investigation and analysis of incidents
- Lack of time and resources dedicated to helping people understand and make sense of disseminated lessons
- Overload of recommendations and failure to agree actions with all the involved parties
- Failure to check that implemented changes have addressed the underlying causes and reduced risk.
In view of these problems the Energy Institute commissioned DNV GL to help it develop a guidance document on LFI. This guidance document is currently at a draft stage, but a recent paper “Guidance on Learning From Incidents, Accidents and Events” describing its key features was presented at the Hazards 25 conference in Edinburgh (13-15 May 2015).