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Learning From  Incidents

Why Do Organisations Fail To Learn From Incidents?

According to the International Labour Organization, every 15 seconds a worker dies from a work related accident or disease, while a further 153 workers have work related accidents.

Accidents and incidents often arouse emotions either due to economical losses, personal injuries, fatalities or environmental damages15. Prevention and reducing the number of incidents is an important objective of all organisations. The literature and previous incident investigation reports indicate that similar incidents are occurring regularly as the majority of organisations have failed to learn from previous incidents. Subsequently, failure to recognise and learn from previous incidents often results in larger incidents. It was argued that ineffective learning from incident (LFI) process and relying mainly on sharing knowledge rather than concentrating on learning process has led to repetition of similar incidents in organisations. This article reviews the recent research works on LFI process and identifies the key factors affecting organisations in this regard.

LFI process model

Learning from incidents, or LFI, is just one of many activities in managing safety in an organisation. LFI is defined as “a process through which employees and the organisation as a whole seek to understand any negative safety events that have taken place to prevent similar future events.” The outcome usually should lead to changes in behaviour or technical process in any organisation if all stages of LFI are properly implemented.

“failure to recognise and learn from previous incidents often result in larger incidents”

The most important element is to understand the process of LFI and how organisations can learn from their own and external undesired events. The process can take anywhere from a few days to several months, depending on the scale of the incident and how widely learning is distributed throughout the organisation. A previous research project in Glasgow Caledonian University has resulted in the design of a learning from incidents process flow chart and framework. This ultimately led to the design of a learning from incidents tool kit to help organisations map their current LFI initiatives against stages of effective process, identify their gaps and ultimately improve their own learning processes.

As indicated in flowchart below, there are six stages in the LFI process. These start from an undesired event and lead to the implementation of action, while incidents outside of the organisation will be processed on the third stage of the process, as reporting and investigation stages are implemented by third parties. The flow chart also indicates that the incidents and near misses are not the only resources for organisational learning, and any health, safety and environmental concerns should be processed to improve the organisation’s overall performance in these areas.

Why organisations fail to learn?

Any organisation learns through its people. In fact, learning occurs when an individual involved in incident extracts the knowledge and converts it into general knowledge for the whole organisation or other interested parties. There is a correlation between learning and risk management process. When an organisation learns, it draws on all the information about emerging risks or the higher risks that it previously considered as low risks. Through the implementation of required control measures to eliminate or mitigate the risks, learning is taking place in organisations and organisations are sustaining the process of continuous improvement, allowing them over time to become highly reliable. In order to understand why organisations fail to learn from previous incidents, various factors should be considered. As indicated in the LFI process chart, problems in any stage will influence the quality of the following stages as well. Unfortunately, LFI is more complicated than we imagined and no simple solution exists for organisations for overall improvement, so we cannot point to single organisational or human factors elements as the main contributory factor for failure of organisational learning. It encompasses a combination of factors, as outlined in the following sections.

Quality of incident investigation

Incident investigation is the most well known section of LFI process. Conducting an incident investigation will provide deeper understanding of the associated risks in an organisation’s work activities. Most incident investigations fail at this stage because they do not get further than the immediate causes. Considering the fact that the majority of incident investigation reports conducted by organisations’ experts lack the required details, including human and organisational factors, this ultimately leads to the identification of ineffective remedial actions and subsequently, LFI processes becoming less effective. It is often observed that immediate and underlying causes of incidents have stipulated, instead of root causes in investigation reports, that indicating, having required expertise at initial stage of LFI process is critical as it is providing inputs into next stage of LFI process. Considering the fact that most incident investigation reports have some degree of uncertainty about the true causes of incidents, the integrity and credibility of the investigators is critical to secure the acceptability of their findings. Overall, improving the quality of incident investigation in most organisations will require significant changes in their culture.

The majority of organisations use a range of incident investigation tools, such as Tap Root, Kelvin TOP-SET, and Fish-bone as stipulated in their incident investigation and reporting procedures, but if the investigation tools are not implemented properly or proper training in use such tools is not provided, the outcomes would influence the LFI process. As incident investigations and conducting root cause analysis are time consuming tasks, often in small to medium scale organisations it is observed that the related employees wondering whether Root Cause Analysis should be performed for reported incidents, which is due to poorly written or non-existent procedures or a lack of training.

Underreporting of incidents in organisations

Management of organisations relies on an incident reporting system to see the flaws in the HSE management system. A robust incident learning system assists organisations in enhancing their reliability. In fact, no organisation can claim to be ‘highly reliabile’ unless it demonstrates that a large number of incidents are reported, investigated, lessons learned and properly distributed and effectiveness of actions have been evaluated. It is clear that in any organisation that has a high level of underreporting, the learning process is defective and would not lead to any major improvement. In an organisation with an effective LFI system the number of reported incidents may increase at the initial stage, but severity of incidents reported will decrease over the time period. Fear of being blamed and the belief that nothing will be done in response to reported incidents have been major barriers to reporting incidents in organisations. Even incentive schemes that reward for the absence of incidents may act as contributory factors for underreporting of incidents, such as a performance bonus linked to the rate of occupational safety incidents, e.g. 1,000 days without an incident in the facility. Moreover, the reporting and investigation procedure also plays a fundamental role, as often it seems some incidents aren't reported by employees due to over complex reporting systems.

“in positive safety culture, it is critical that managers and supervisors encourage open communication”

Correlation of positive safety culture and LFI process

Establishment of learning culture implies promoting the desire of all involved parties to learn from transferable knowledge found in the incident reports. There is no need to accentuate that better established safety management systems and positive safety culture have a direct relation to the robustness of incident learning systems in any organisation. For instance, if an organisation doesn't have proper management of change process, the proposed remedial actions following the incident may lead to other unforeseen problems. Just as LFI is a human driven process, poor safety culture in organisations also leads to less reported incidents, poor quality investigation reports, less knowledge sharing, inefficient procedures and consequently ineffective learning process. It’s for this reason that all employees should be involved in LFI initiatives and have the opportunity to influence learning processes.

The literature review indicates that there is a significant relationship between safety culture and learning culture. Open communication, employee empowerment and collaboration are typical common themes that exist in learning culture and safety culture. For example, in positive safety culture, it is critical that managers and supervisors encourage open communication. Employees should be able to discuss their issues with managers openly while in a positive learning culture, which requires transparency through open dialogues via multiple channels of communication.

Role of organisation leadership

Leadership is fundamental for an effective learning environment. Leaders should encourage open reporting of incidents and act as champions in enquiries and catalyse changes in response to learning, while persuading others to draw on their own training and apply it to their day to day work.

On the contrary, poor leaders could inhibit learning, for example reacting badly to reports and seeking to apportion blame. Leaders’ understanding and ability to direct conversations with employees to positive learning outcomes is critical for the development of the workforce and improving safety culture.

Certain leadership behaviours can improve incident investigation practices and improve LFI process. For instance, asking for structured incident investigations to identify direct and root causes of incidents, and allocating sufficient resources and time for incident investigations are typical leadership behaviours that improve both practices and processes.

Sharing knowledge is different from learning

The majority of literature reveals that dissemination of incident alerts by organisations has been considered as LFI, but in doing so other important stages of the process have been ignored9. Especially when considering that some companies simply distribute incident safety alerts to other sections and expect LFI to be implemented without further facilitations, such as sense-making workshops, implementation of actions, and follow up3. Moreover, not all organisations are interested in sharing their incidents with external parties. There is considerable variability in the degree of openness and willingness to share information on accidents and incidents between companies in different sectors of industry. In the case of sharing, most of the time technical issues are disclosed and root causes are not mentioned, thereby limiting the opportunities for learning.

Lack of understanding on distributed incident alerts

Transferring LFI to company employees, particularly shop floor employees, is often challenging. Neither individuals nor organisations can learn effectively without reflection and making sense of the whole situation. Individuals need to understand the context of the incident in order to draw insights so they can apply it to their workplace. To achieve this, the required resources need to be provided. Communication of lessons learned could be achieved through various methods, such as private dialogues between employees or in a structured form such as a workshop led by experts or line managers.

Each method has its own advantages and disadvantages. Lack of sense making or understanding of transferred information has been seen as one of the major issues in the incident learning process. It could be due to ambiguity of the data or complexity of the incident, particularly if the incident alert was not relevant to the employees work, causing employees to become reluctant to accept the message unless LFI accentuates behavioural aspects in addition to technical or procedural failures.

In addition to this, some organisations tend to illustrate complex incidents to their employees in simplified ways to spread the message. In doing this, the organisation’s employees fail to understand the true causes of incidents9. It is often observed that employees ignore the incident alerts due to poor presentation by involved parties or not allocating required time for feedback. Most employees prefer the use of visual aids such as animations or video clips to make better sense of what has happened and what could be done to prevent such an incident occurring in the future. Any developed material for learning purposes should include technical, procedural and behavioural aspects of incidents to have a better impact. The creditability of the presenter is critical as most people prefer the imparting of knowledge to be carried out by someone who has been involved in incident, rather than second hand from someone like a supervisor or manager.

Learning approaches and a lack of required resources

There are two different approaches to learning in any organisation. Most employees prefer the presentation to be performed by top management/leaders in a structured way (formal learning) rather than to get them from various sources, e.g. informal talking between employees about issues or to gather data through the emails or social networks (informal learning) which, although still most likely valid, is not credible. Demobilisation of employees from organisations also could not been seen as a sustainable approach in this type of learning process. Furthermore, the complexity of incidents or near misses defines the required learning approach. The learning approach for an incident that had led to catastrophic and whole site failure, such as the Chernobyl disaster, requires a different approach to one that involves a single individual, such as a forklift incident.

A lack of the required resources such as allocation of time, money and people in all stages of the LFI process have been significant contributory factors in organisations’ failures to learn. It is not possible to learn from incidents in an effective manner without the allocation of the required resources. A lack of competent incident investigators, inadequate human resources for implementation of remedial actions and follow up, insufficient allocation of required time, and budget for modifications of process or other required remedial actions such as incident sense-making sessions would lead organisations to fail to learn from unwanted events.

Legal issues in LFI process

Legal aspects of incidents are becoming more restrictive for LFI process, causing an obvious obstacle for appropriate communication of incidents with concerned parties and adverse effects on learning processes. Legal issues are also causing a significant delay in the dissemination of information. It may enhance claim culture, detrimentally causing an increase in the risks. Early engagement with the legal team and explaining the objective of LFI to them could lead to better advice on legal risks. In addition, having access to legal advice in incidents which are likely to lead to criminal proceedings may be helpful in this issue.

Role of enablers of learning

Various parties are defined as enablers of learning from incidents. In fact, as external organisations these parties have a fundamental role to provide insight. Having a good relationship between organisations and these external parties is fundamental to improving learning processes. Regulators and national bodies, workshops and conferences, professional bodies, learning agencies, and national enquiries following disaster, are all typical enablers of learning. For instance, the public enquiry following the Piper Alpha disaster had valuable learning points for the majority of organisations active in high hazard industries and the lessons learned were applied globally.

No implementation or evaluation of remedial actions

The main problems arise in performing the actions and evaluation of remedial actions where remedial actions have often never been implemented or the effectiveness of implemented actions has not been measured that ultimately cause the LFI process to become ineffective. In addition to this, in most organisations investigation and recommendation phases occur simultaneously. By doing this, there is a tendency to opt for quick-fix approaches and sometimes recommendations are made without an understanding of an incident’s causation. It can also lead to simple and inexpensive solutions for more serious root causes.

The recommendations phase is critical yet it has been seen to be ignored by related line managers, potentially because they were either never consulted on their suitability or did not have the required resources and time. In addition to this, in some cases recommendations might not be accepted by frontline employees so long as they believe that the investigators and line managers misunderstood the events and true causes of an incident.

Ineffectiveness of remedial actions could be due various reasons:Implemented actions ineffective due to a lack of resources (money, time, people) or causes other unforeseen risks or no tracking and follow-up actions are in place

  • Lack of prioritisation of actions or no action defined, responsible person was not assigned
  • No one checked the proposed remedial actions, people fear proposing actions like a change in design, due to fear of top management
  • Easier actions implemented but more complex actions left unattended for a long time
  • Only a quick fix approach is used and root causes of incidents are either never addressed or delay time on decision for remedial actions
  • Remedial actions were either not meaningful or inappropriate to the level of risks or nature of incident
  • Remedial actions were unrealistic or overall recommendations are not SMART (specific, measureable, achievable, realistic, time bounded)
  • Lack of management commitment for implementation and follow up or cultural issues in organisation
  • Defective incident investigation methodology lead to improper proposed actions
  • Competency questioned in relation to incident investigation, outsourced experts or competency required in devising remedial actions
  • Resistance to changes or other existing organisation priorities for implementation of remedial actions
  • Action is not closed out due to individual risk perception

All mentioned issues would mean the learning cycle is not completed and there is a high likelihood of a similar incident reoccurring in the organisation’s future.

“organisations with effective LFI systems sustain a process of continuous improvement that allow them over time to become highly reliable organisations”

Improving LFI processes

Any approach for improvement should consider LFI as a whole, rather than as a separate stage of the process. Most organisations just concentrate on one or two stages and so are only able to improve marginally for overall learning process. It is often said, “If you don't measure it, you can’t manage it” so to identify existing LFI systems the LFI Toolkit was developed by Glasgow Caledonian University. This includes various workshops by involvement of line managers and assists organisations in exploring their current LFI system and identifying any gaps and inconsistencies. Conducting a survey to gauge employees’ perception and their commitment in relation to LFI system is a valuable exercise and will help to draw up an appropriate intervention plan.

Conclusion

Literature review indicates that the majority of organisations consider dissemination of incident alerts as the final stage of LFI process, but in doing so other stages of LFI process, in particular the contextualisation stage, have been overlooked, meaning key opportunities for learning throughout the incident lifecycle are missed.

To improve LFI process, organisations should analyse each stage of LFI process, identify the bottlenecks that may occur and apply a range of remedial actions for improvement. Due to a range of variations that are related to organisation LFI process, long term objectives need to be set by the organisation's management for improvement of the LFI system. The organisations with robust HSE management systems and a positive safety culture also have better learning from incident systems. Organisations with effective LFI systems sustain a process of continuous improvement that allow them over time to become highly reliable organisations.

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Shahram Vatanparast is a chartered safety and health practitioner and fellow member of IOSH with more than 16 years’ experience in the upstream sector. He has worked for major operating companies such as TOTAL, PTTEP, ENI, SINOPEC in Middle East and South Asia regions, both on the offshore and onshore fields. He is the managing director of Petro Santa Imen Avin Company, which provides a ranges of consultancy services including IOSH and British Safety Council training courses.