(110b) Lessons Learned - How to Make Them Stick

After an incident investigation we gather the facts, assign causes and compile a set of lessons that should, if learned well, prevent a similar incident from occurring. Unfortunately, too often we see the same type of incident happening, sometimes in the same company that had the original incident, or in a company using the same process technology as the company that had the incident. What happened? Are we not learning the lessons? Not because we are not trying. Besides monthly AIChE bulletins, a joint GCPS track on the subject, CSB videos, and countless articles – in the last twenty years 297 articles on lessons learned have been published in Process Safety Progress – we continue to have similar incidents. The reason is that we don’t learn by listening to a talk or reading a bulletin, at least not for the long term. Our memory fades with time. Even if not, we still need to relate the incident findings to the planning and execution of our work. Thus, the way to remember those lessons is by making them vivid when training, adding them to a well-designed knowledge repository, incorporating them in our technology and daily operations, and periodically reinforcing them. If we manage to do that, there is a good chance that the lessons will be woven into the fabric of the company and incidents will not be repeated. These methods will be detailed in the paper.