Harvard Business Review recently published an article entitled “Why Organizations Forget What They Learn from Failures.” Having participated in many incident investigations and risk assessments, I have witnessed this process first hand. It is a reminder to have a work process to institutionalize the learnings from your plant and other plants.
A key step in institutional learnings from previous accidents is to be transparent within your organization about all the factors that led to the event. Root cause identification systems commonly have multiple causal factors. These causes should be boiled down into a summary write up (1-3 pages max) that outlines the scenario and prevention measures. We have done this for a number of clients with great success. Burying the report in a corporate incident reporting database does no good. Rehashing these events on a semi-yearly basis as operations teams cycle through keeps the most important learnings fresh. Once a number of these summaries have been developed, they can serve as part of the new hire or new transfer to a particular unit’s training process.
An actuary once told me that for every 1 significant accident that happens, a similar set of circumstances has occurred 7 other times at other facilities. The only difference is “luck” and their other plant “got away with it.” Let that sink in….. Just because a bad event has not occurred at your plant in a recordable fashion, it may have….. Sharing stories across corporate boundaries is critical to preventing the next incident from occurring.
RefComm and Coking.com have been devoted to sharing the lessons learned in our industry for the past 17 years. From every conference, people come away with all types of experiences to share with their plant. If just one of these nuggets of information leads to avoidance of a serious injury or accident, we all win. Join us in May at the Moody Gardens Convention Center and restart your focus on safety.