Lessons in safety - April 24

UNPOPULAR FACT alert: learning can frequently be challenging. And organisational learning is no exception. It requires individuals to experience and learn, share that learning, collate, interpret, document and disseminate that learning, and act upon it. The participation, influence and motivation of individuals in the process will vary too, making it hard to accurately capture the reality of a situation. As workers move on and new people join the organisation, experiences, learning and memories are forgotten. Add in multiple organisations through supply chains and regulatory bodies, and you can see how complex it can become. 

Of course, in some instances, the consequences of not learning are more severe than others. But when it comes to health and safety, the failure of organisations to learn can be catastrophic. Take, for example, a 2018 refinery explosion and fire in Wisconsin; the subsequent report from the U.S. Chemical Safety and Hazard Investigation Board identified, amongst other things, a lack of process knowledge, failure to maintain process safety information and operator training, and failure to learn from a similar 2015 incident (the lessons from which had been distributed via industry trade groups).¹ 

Every organisation is unique, and so will be its way of learning. But there are things we can all do: 

• Effective incident investigation
  Many incidents have minor consequences because there are often subsequent safeguards (by luck or design) that prevent further harm. But what if multiple safeguards – that may have all failed in the past with minor consequences - fail at once? The outcome can be a major incident. That’s why we have to effectively investigate minor incidents so that they don’t contribute to a major incident. 
• Record knowledge
  As you update processes, policies, working instructions etc. record the data and reasoning for why changes have been made. You could include this as an appendix so it stays with the document(s) and there’s a single source of information. 
• Make it accessible
  Do the people that need it, have easy access to the information they need to work safely and make informed decisions? 
• Consider combining Safety I and Safety II philosophies
  Adopting an approach that blends Safety I’s stability with Safety II’s adaptability. This integration can help to create a more resilient and learning-oriented organisation.
• Learn from others
  Organisations such as the Health and Safety Executive, the UK Institution of Chemical Engineers, the Chemical Safety Board, the International Association of Drilling Contractors and the Responsible Care programme all publish various bulletins, reports and videos to share lessons learnt from safety incidents.  These are provided by way of example; your industry may have others, too.

This column just scratches the surface of organisational learning but hopefully I’ve given you some motivation and ideas to make a start. The NEBOSH HSE Cerificate in Process Safety Management explores this topic in more detail – an industry where individual and organisational learning is crucial to keep people, communities and the environment safe. 

¹ https://www.csb.gov/-final-report-into-2018-husky-superior-refinery-explosion-and-asphalt-fire-in-wisconsin/?pg=4 

Matt Powell-Howard is head of product development at NEBOSH. For more information, visit: www.nebosh.org.uk