(152d) Learning from Incidents - a Practical Application

?By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.? -- Confucius

It is only the true innovators who can learn by reflection, for the rest of us we need to learn by either imitation or experience. When we consider experience in the context of industry, this is often equipment damage or personal impact such as injuries or fatalities. Considering that recent research suggest the Naturalistic Decision Making model is used by experienced people when making daily decisions, it is important to provide varied patterns for recognition in this decision making, especially when considering low frequency, high consequence outcomes where there may not be direct experience.

This paper focuses on some practical applications of learning from incidents outside the immediate workplace. This is as important an area to focus on as incidents within the workplace because it enables demonstration of consequences when looking at low frequency, high consequence incidents, incidents which a person may not have ever seen before. Under a Victorian Safety Case regime, incidents need to be considered when identifying hazards. This assists is identifying hazards which may lead to low frequency, high consequence risks.

To be able to effectively learn from incidents, firstly we need to select the ?right? incidents to learn from. Then we need to determine Root Causes of the incident. Once Root Causes are understood a gap analysis can be performed to determine any necessary actions. Once actions are implemented they need to be reviewed for effectiveness. Throughout this process employee engagement is vital. Without effective engagement of the workforce when performing such tasks as a gap analysis, effective application of learnings may not be achieved. This may result in a situation of not actually learning from the incident and possibly being doomed to experience it.

The paper includes some examples of how learnings have been applied at Australian Vinyls Laverton Plant in their Safety Case Submission and resources available for information.