Learning lessons
Learning lessons involves acting on:
- findings of accident investigations and near-miss reports
- organisational vulnerabilities identified during monitoring, audit and review processes
Even in well-designed and well-developed management arrangements there is still the challenge of ensuring that all requirements are complied with consistently.
After an accident or case of ill health, many organisations find they already had systems, rules, procedures or instructions that would have prevented the event but were not complied with.
The underlying causes often lie in arrangements which are designed without taking proper account of human factors, or where inappropriate actions are condoned implicitly or explicitly by management action or neglect.
Common factors when things go wrong
Analysis of major incidents in high-hazard industries, with different technical causes and work contexts, has identified several common factors involved when things go wrong. These factors are related to:
- leadership
- attitudes and behaviours
- risk management and oversight
When these aspects of an organisation become dysfunctional, important risks can become 'normalised' within it, leading to serious consequences.
Organisational learning
Organisational learning is a key aspect of health and safety management. If reporting and follow-up systems are not fit for purpose, for example if a blame culture acts as a disincentive to reporting near misses, then valuable knowledge will be lost.
If the root causes of precursor events are not identified and communicated throughout the organisation, this makes a recurrence more likely.
In many cases, barriers within an organisation - where different departments operate in 'silos' - inhibit organisational learning.
Human factors
Leaders and managers need to be aware of the people-related, cultural and organisational issues that may prevent lessons from being learned effectively in their organisations.