When things don’t work out as planned, and controls fail, an incident may happen. We investigate to understand the causes and how we can prevent them – but we should not stop there. We must try to communicate the findings so that others may benefit. In this way, we can proactively change behaviours and processes and have a wider impact.
This is why our new course, “Learning from Incidents”, focuses on implementing the changes needed to prevent incidents from happening in the first place.
The course helps participants understand that:
- Learning is demonstrated by a change in ‘practice’ (i.e., a change in how things are done)
- For people to change their practice, they must relate knowledge about an incident to their own work situation
- People learn by actively engaging with information
- Some knowledge is written down, but a lot exists only as ‘practice’ or ‘culture’
- Knowledge that cannot be simply written down in a new procedure may best be learned on-the-job
- Learning needs to be two-way
Our Learning process
We use the Swiss cheese model of an incident causation
Our course explains that:
- Hazards are contained by multiple protective ‘barriers’
- Barriers may have weaknesses or ‘holes’
- When holes align hazardous energy is released, resulting in the potential for harm
- ‘Barriers’ may be physically engineered or behavioural
- Holes or failures can be ‘latent’ or ‘active’
To prevent recurrence, our course focuses on the following questions:
- What are the existing controls in place to prevent this?
- Why didn’t the existing controls work?
- Fix or improve existing controls before creating new ones.
- ‘Stabilize before optimize’
- What additional new controls must be put in place?
- Develop recommendations for corrective and preventive actions for each of the causes that have been identified.
To find out more please get in touch with enquiries@inverroy.com
