Not adequately learning from lessons of past process safety events has proven to be a critical issue that hampers organizations within the energy industry. This has led to recurring process safety events that often arise from very similar contributing causes. These contributing causes are typically not new learning’s to investigators but rather a regurgitation of what was previously learned through past events.
Best practices to improve memory of process safety learning’s are available, and yet the problem still exists. The question is therefore asked; is something missing within these suggestions for improving memory?
Thesis set out to develop a tool to aid ConocoPhillips Canada in preventing memory loss that is contributing to process safety events. Some of the world’s worst process safety accidents were reviewed to gather common learning’s, and investigation reports of ConocoPhillips past process safety events were analyzed to determine how prevalent the issue of memory loss is within the company. Best practices to prevent such memory loss were researched and found to be readily available, and yet for some reason memory loss issues are very widespread. The cognitive sciences were then looked to for an answer – how memories are developed and effectively retained. The field of education was researched, to determine how leading educators effectively teach learning to achieve high levels of memory retention. Through this the taxonomy table, a tool that has been used to enhance teaching and learning for many years, was discovered. Then, effective safety communication methods that target memory retention, including emerging technologies, were explored. All researched information was finally tied together, into a learning curriculum, consisting of various learning activities. These learning activities were constructed, with the aid of the taxonomy table, to advance the learning process towards an objective that had been carefully developed. This objective was for the workers to integrate past process safety learning’s to prevent future process safety events.
The primary finding of this work has been the importance of intentionally targeting learning and memory retention in the field of process safety. There are effective practices to improve the learning process and enhance memory retention. It is key that these are implemented along with existing industry best practices for remembering past process safety events. Only when these are combined can an organization effectively remember and use past process safety learning’s to prevent future process safety events.
ConocoPhillips Canada is now utilizing learning's from this study to develop a learning curriculum, consisting of various learning activities, to integrate past process safety learning’s to prevent future process safety events. These learning activities will be shared as part of the presentation.
The primary focus of learning activities is in the area of Operations Integrity.
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