(120c) Never Again - How to Remember Lessons Learned

One of the most important and most challenging opportunities in process safety is learning from incidents and near misses and remembering those lessons. The importance of this is recognized in CCPS Vision 20/20 tenet “Enhanced Application of Lessons Learned”. Too often when companies think of learning from incidents, they literally think of learning rather than thinking about what changes can be made so that similar incidents never happen again. Learning is an important aspect of preventing the incident in the future; however, several other activities will minimize the probability of the incident recurrence. Activities such as updating operating and/or maintenance procedures, modifying standards for existing equipment, and updating bow ties may help to sustain the learning. Prerequisites to the learning from incidents include robust process safety management systems to ensure that root causes are understood, incident/near miss technical details are clearly communicated, and action items are implemented. The purpose of the paper is to present ideas and examples to help companies confidently say, never again.