In almost all organizations, incidents are analyzed and lessons learned are identified. Effective learning from incidents (LFI) fosters transformational learning and, as such, reduces the risk of incidents recurring that have the same or similar causes as an incident that has occurred (and been investigated) in the past. While many hard-won performance improvements have been delivered over the long term, achieving the next level of performance will require more than just incremental improvements.
Although many organizations may struggle to learn effectively from incidents, relatively little is known about the specific bottlenecks in the LFI process. This paper provides insight into the most probable cause of lost learning potential: the implementation of interventions and evaluating their effect. A disconnection between those who investigate and those who implement actions could be one of the causes of a lack of substantial improvement over the past decade. In this paper, a process-oriented approach is presented in which the bottlenecks in the LFI process will be described and how the main issues were addressed at Shell Downstream Manufacturing by having “create more engagement in leaders” as one of the main objectives.
This paper will provide practical insights into what it takes to improve the engagement of leaders for the learning process itself. It will present a number of “I” statements to help leaders understand what they need to do as part of the change journey to take learning from incidents to the next level.
According to a report from the International Association of Oil and Gas Producers, the number of incidents in the petrochemical industry appears to be stable. Given that the nature of the incidents has not shifted significantly, the learning potential of the incidents apparently has not been optimally utilized. Many companies investigate incidents to understand what exactly happened and what they could have done to decrease the likelihood of re-occurrence of similar events in the future.
A common assumption is that careful analysis of incidents and documentation of learning points will lead to the desired results. However, although the research and analyses is necessary, despite how carefully they are conducted, they are certainly not sufficient for the learning process.
Learning from incidents is a fundamental aspect of the safety policy of companies. Yet few succeed in getting the number of incidents down to a sustainable basis because of, among other things, inadequate learning from incidents from the past. In this context, we consider incidents as undesirable deviations, particularly in primary or supporting processes. Incidents, thus, can be seen as warnings or symptoms of suboptimal process control. By learning from incidents, companies can address the causes, and the resulting continuous improvement contributes to a reliable and safe process with fewer incidents.
Learning from incidents is intended not only to reduce potential repetition but also to improve the learning process in general. Usually, the implicit assumption is that learning from incidents will be adequate when the analysis is performed with care and lessons are formulated to help mitigate repetition of incidents. To learn from incidents effectively, however, some follow-up steps and actions that lead to effective interventions are necessary. The learning process itself should be evaluated. Learning, therefore, not only should be aimed at learning from an incident itself but also should focus on learning from the outcome of an incident analysis. Only then can a company identify deviations in the business processes in time to cope with them and thereby realize continuity in the improvement. To achieve this, it is necessary to reduce the potential for repetition of incidents by taking appropriate measures at the level of the identified causes and assessing their effectiveness. In short, the entire process, from the occurrence of the incident up to and including the evaluation of the implemented measures, needs to be improved.
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