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Principles for learning lessons from incidents – a UK ...

Principles for learning lessons from incidents AUK PERSPECTIVED eborah Keeley1, Sandra Gadd1, and Brian Fullam21 Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire, SK19 9JN, UK2 Health and Safety Executive, Magdalen House, Stanley Precinct, Bootle, Merseyside,L20 3QZ, UK#Crown Copyright 2006. This article is published with the permission of the Controller ofHMSO and the Queen s Printer for ScotlandThis paper presents the findings from a project conducted by the Health and SafetyLaboratory (HSL) for the corporate Science and Analytical Services Directorate ofthe Health and Safety Executive (HSE).

oratory (HSL) on behalf of the Corporate Science and Knowledge Unit, part of the Cor-porate Science and Analytical Services Directorate of HSE. The purpose of the work was to examine existing arrangements for learning lessons from incidents within UK industry and HSE, in order to enable HSE to establish a future policy for how to effectively

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Transcription of Principles for learning lessons from incidents – a UK ...

1 Principles for learning lessons from incidents AUK PERSPECTIVED eborah Keeley1, Sandra Gadd1, and Brian Fullam21 Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire, SK19 9JN, UK2 Health and Safety Executive, Magdalen House, Stanley Precinct, Bootle, Merseyside,L20 3QZ, UK#Crown Copyright 2006. This article is published with the permission of the Controller ofHMSO and the Queen s Printer for ScotlandThis paper presents the findings from a project conducted by the Health and SafetyLaboratory (HSL) for the corporate Science and Analytical Services Directorate ofthe Health and Safety Executive (HSE).

2 The aim of the work was to examine existingarrangements for learning lessons from incidents within UK industry and HSE, and toidentify the key elements of an effective system for learning lessons from work also identifies sound Principles to be applied for the collection and dissemi-nation of information and discusses significant weaknesses and gaps in existingarrangements. Recommendations are given for improvement within both HSE andUK industry. The study does not address the mechanisms needed to implement of the findings from this research was that ongoing investigations and prosecu-tions sometimes act (or are perceived to act) as barriers to learning by impeding therelease of information on lessons learned.

3 In response to this finding, and to related con-cerns from elsewhere, HSE have commissioned HSL to investigate in more detail theimpact of possible legal action on the dissemination of information on lessons that lessons are learned from previous incidents so that identical or similar acci-dents arising from work activities can be prevented in the future is central to the Health andSafety Executive (HSE) mission, to protect people s health and safety by ensuring thatrisks arising from work activities are properly paper presents findings from a project conducted by the Health and Safety Lab-oratory (HSL) on behalf of the corporate Science and Knowledge Unit, part of the Cor-porate Science and Analytical Services Directorate of HSE.

4 The purpose of the workwas to examine existing arrangements for learning lessons from incidents within UKindustry and HSE, in order to enable HSE to establish a future policy for how to effectivelyidentify and promulgate lessons learned from incidents at all levels. The project had thefollowing aims:.To examine existing arrangements for learning lessons from incidents within UKindustry and HSE;.To capture examples of good practice in existing arrangements;SYMPOSIUM SERIES NO. 151#2006 Crown establish sound Principles to be applied for the collection and dissemination ofinformation; identify significant weaknesses and gaps in existing arrangements and developoptions for remedying scope of the work was extremely broad, covering all sectors of industry (both HSE andLocal Authority enforced) and being concerned with lessons learned from safety and ill-health related incidents .

5 All types of incidents (accidents, incidents and near misses) werewithin scope with the exception of those major accidents that have resulted in a approach adopted consisted of the following tasks:.Literature and internet search and review focussed on material concerned with thepolicy and Principles of learning lessons ;.Interviews with HSE staff with knowledge of how companies/organisations currentlylearn from incidents and HSE s involvement in the process; with a small sample of representatives from industry bodies, Principles FOR EFFECTIVE learning AND GOOD PRACTICEA detailed review of the information collated on the existing arrangements in HSE andindustry with respect to learning lessons was undertaken, and good practice guidelineson how to learn lessons and share information have been drawn out.

6 This was informedby the discussions held with HSE staff and representatives from industry was found that an effective system for learning lessons from incidents would needto include the following elements:.An incident /accident reporting system;.A process for incident investigation that ensures that the underlying as well as immedi-ate causes of accidents and incidents are understood, taking full account of human andorganisational factors;.A process for analysing cumulative information on accidents and incidents from bothinternal and external events.

7 A process for ensuring that the findings of incident investigation and analysis of acci-dent and incident data are acted upon in a timely fashion and suitable interventionsput in place or modifications made to prevent a recurrence of the incident or similarincidents;.A process for evaluating the success or otherwise of interventions and modifications;.A process for disseminating information on accident and incident causation and suit-able interventions/modifications to all relevant parties (both internal and external), asquickly as possible; system to capture the information in a format that is readily searchable and retrieva-ble to allow ease of access, so that any lessons learned stay learned ( corporate memory).

8 SYMPOSIUM SERIES NO. 151#2006 Crown Copyright2In a well managed organisation, the elements of an effective learning lessons process out-lined above (with the exception of elements of dissemination of information) should formpart of a good health and safety management system. That is, it should not generally benecessary to have a separate learning lessons system. Companies with good generalhealth and safety management were found, in general, to also be best at learninglessons and having positive health and safety cultures; this tended to be the bigger com-panies in major hazard/high profile should also be noted that employee involvement is essential for the process andsystems listed to be effective.

9 The role of employees, including safety representatives,is particularly important for effective incident reporting and investigating was found that many large companies had some formal processes (for example,systems for recognising, investigating and recording incidents ) although the quality ofthese was variable with some being very good and some comparatively poor, while themajority of small firms do not have any, although some do have informal is also a high degree of variability between different sectors of industry interms of how well developed and sophisticated the learning lessons processes andsystems are.

10 For example in the aviation, offshore, nuclear and hazardous chemicalssectors companies generally have structured and established systems. In these sectors,there are specific regulatory requirements to have particular processes or elements of alearning lessons system in place. Conversely in sectors dominated by SMEs, forexample the commercial and consumer services and agriculture sectors, such systemswere generally either absent all together or are much less formal and following sections describe each element of an effective learning lessonssystem in more detail, including examples of good practice.


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