Will We Ever Learn

A snippet – Will We Ever Learn

As some of you already know, I am working on a new idea. Will it be a book? Maybe. We will see. It is still very much work in progress but I want to share what I have got so far. It has a working title of Will We Ever Learn? I have lots of ideas and want to share them with as many people as will listen. It is what I do and love.

I looked up, read reports and books about, summarised and studied, 23 major catastrophes from across the globe. They range from chemical explosions and exposures, ferry disasters, fires, space shuttle fails, and nuclear incidents. I aimed to explore the lessons that were either not learnt prior to the incidents and should have been, or lessons that need to be learnt after the incidents.

I endeavour to answer the perennial question of why we are not learning from incidents within our own businesses and industries, but also why are we not learning from other industries and countries, and critically, how we can get better at it?

For example, if you run an electricity supply ‘wires and poles’ business, what can you possibly learn from a space shuttle incident related to foam shedding? You probably have not asked that question. You should as the answer turns out to be ‘a lot’.

In an industrial or business sense, learning from incidents, audits, reports etc. is more than embedding the findings from those activities. It is more than sharing one-pager summaries at pre-start worker meetings. It is more than putting up posters. It is more than telling people to be careful as such and such thing has happened somewhere else and we need to make sure it does not happen here. What we want to achieve is long-term changes in the way people work as a result of changes in the way people think and in what they believe. This means that to learn anything we need to really internalize the lessons to be learnt, understand them and make them part of what we do and who we are.

Whether your incident investigation method is Essential Factors, MORT charts, ICAM, 5-whys, Learning Studies, Learning Teams, or one of the myriad other investigation / learning from incidents techniques, a part of the process needs to think about what the broader business needs to learn from the incident – what is it that we need to change?

Generally the businesses I have come across over the last 45 years that I have been working are somewhere between poor and reasonable at sharing the findings of workplace incidents with their employees. Only a small percentage are good at converting that which is shared into lessons learnt. i.e. changes in the way their employees think and more importantly, behave.

To maximise learning in an individual, we must remember that you cannot force learning on someone and expect it to be sustained. If you want someone to learn, you want to get to a point where the individual recognises that the current way of doing a piece of work is not the ideal way to do it, starts to think differently about that, sees the need for change and after experimentation and some conversations, ‘gets’ that the new way is maybe safer, easier, quicker, and maybe more satisfying. This is very much about workers getting the ‘Why’ of the lesson to be learnt.

Of course, in an industrial setting, any changes in the way work is done or changes in individual’s behaviour needs to be supported and facilitated through systems, leaders’ behaviour etc.

Learning in this context is a deliberate activity, driven by something that has happened either in the business itself, other businesses within the same or similar industries or something completely left field such as the space shuttle incident I mentioned earlier.

A good way of activating this deliberate approach to learning is to embed the learning and targeted/new work into observable behaviours.  Aim to embed it in normal work – the way we do things around here on a day-to-day basis. This can be further enhanced by ensuring the individuals are involved in interactions with each other, have time for experimentation and assessment / reflection and feedback. Networks are a great way to foster this.

Learning, especially workplace learning is complex.

So, in summary, the implication is  that if an individual ‘gets’ an idea and then finds out through different thinking and acting, talking, testing, playing, that the new way is a better, easier, or a smarter way of doing a task, then we can say that they have learnt something. And that the new way, the act learnt, will more likely become embedded in the way that work is undertaken. Especially if the ‘getting’ of the new learning is enhanced through socialising the participatory practice with peers et cetera.

What do we see as the key lessons that needed to be learnt, and need to be learnt from the 23 catastrophes that I examined?

Firstly, a list of what the incidents are:

I have been studying some of the most significant catastrophes from the last 50 odd years looking for lessons that we could’ve should’ve learnt before the incident and which we should probably learn after it. From these, I have extracted what the various reports and books believe the lessons are. I have grouped them and created a list of the top 12.

The catastrophic incidents examined are:

Bhopal, 1984

Chernobyl, 1986

Space Shuttle Challenger, 1986

Herald of Free Enterprise, 1987

Piper Alpha, 1988

Space Shuttle Columbia, 2003

Deep Water Horizon, 2010

Fukushima Daichi, 2011

Three Mile Island, 1979

Toulouse AZF Fertilizer Plant, 2001

West Fertilizer Company, 2013

Texas City Explosion, 2005

Flixborough, 1974

Longford Esso Plant, 1998

Gretley Mine, 1996

Costa Concordia, 2012

Flight AF 447, 2009

Sewol Ferry, 2014

Lac-Megantic Train Explosion, 2013

Phillips Explosion, 1989

DuPont Toxic Chemical Release, 2014

Grovepark Mills Explosion, 2004

Pike River Mine explosion, 2010

The top 12 lessons are, in order of prevalence in the reports and books on the catastrophes:

1. Learning from Incidents and Audits

Lesson to be learnt:

• We need to learn from day-to-day operational experience, adverse process events / upsets as well as incidents, both internal to, and external to, the operation, business or industry. These lessons must be converted into changes in the way work is being done and behaviours at appropriate levels of the organisation.

2. Understanding of process, equipment, experience, competence.

Lesson to be learnt:       

• There needs to be a high level of understanding and competence amongst operators, supervisors et cetera around how a plant needs to be operated, how to manage emergency situations, what the impact of change might be, the process basis of design, what is driving any differences between Work-As-Done and Work-As-Written, and where expertise lies for the various processes and activities that the business undertakes.

3. Procedures and risk assessment

Lessons to be learnt:

• Procedures and their like must be easy to follow correctly and difficult to misinterpret.
• They must be followed or changed, cover critical and trigger steps and be based on solid risk assessment processes.
  • These risk assessments must cover Process and Catastrophic risk, in addition to conventional safety risk, including measurement.

4. Critical processes

Lessons to be learnt:

• Critical activities must always be guided by written, known, accurate and utilised procedures,
  • They must flow through all levels of an organisation, from high-level business-wide risk assessments, through site specific risk assessments, procedures, training and verification processes.
    • These verification processes must drive verification in the field by those who understand the criticality of the process or activity.

5. Emergency planning and processes.

Lesson to be learnt:

• Early pre-work must be done to think deeply about what could go wrong, what an emergency response to it might look like, how that response may add risk in other areas or to a local community, and how we might prepare our internal and external responders, along with our employees on how to handle the identified potential emergency situation.

6. Management of Change (MOC)

Lesson to be learnt:

• Systems must force change to be managed, not only for technical changes but also changes in the organization, people, policies and procedures and must cover, often in a more simple way, on-the-spot changes.
  • The process must be followed and verified as completed, or changed.

7. Leadership

Lessons to be learnt:

• Leaders, at all levels, need to search for, and maintain mental models of the work being done on their watch that aligns with the mental model of the work as understood by those who do the work.
•  Leaders must let expertise lie where expertise lies, and set up processes and practices that show that they listen and react to their people.

8. Cost and production pressures

Lesson to be learnt:

• Paying lip service to the impact cost and production pressures can have on safety and safety outcomes. Leaders must deeply understand the impacts their business decisions have on safety and safety outcomes.

9. Shift handover and communications

Lesson to be learnt:

• Communication is not ‘telling’. Communication is a two-way street and is only done when we are absolutely sure that both sides of the communication have a shared mental model of the topic.

10. Drift

Lesson to be learnt:

• Drift must be identified, especially incremental drift over time, through verification and challenge processes to ensure what was once critical, does not becomes Work-As-Normal.

11. Key Performance Indices (KPI)

Lesson to be learnt:

• We can, and need to, measure leading, qualitative, process and other measures that drive safety related behaviours,  and not just the easy lagging, quantitative and safety outcome measures that we normally look at.
  • We also need to consider any potential unintended behaviours of our KPIs.

12. Maintenance and poor equipment

Lessons to be learnt:

• When we come across a sub-optimal design in a plant or piece of equipment, rather than proceduralize our way around it, we need to fix the issue.
• We must fix what is broken, not simply apply easy fixes to problems.

In Summary:

In my book, and also in other, upcoming blogs, I will talk more about ‘how’ we do this learning thing in more detail. To give you a flavour for this, let’s look at one of the lessons to be learnt and what it might look like in a workplace setting once learnt:

The most common lesson not learnt is around failing to learn from previous incidents:

• We need to learn from day-to-day operational experience, adverse process events / upsets as well as incidents, both internal to, and external to, the operation, business or industry. These lessons must be converted into changes in the way work is being done and behaviours at appropriate levels of the organisation.

Success in this lesson could look like the following:

The business has:

There are many other examples for each of the 12 lessons that need to be considered and we have not got time for all of them here, or the detail about how they could be implemented, but; In the meantime, remember that we need to learn from normal operation. We need to learn from incidents within our own businesses. We need to learn from incidents in our, and other industries and countries, and finally, we need to be always asking ourselves these sorts of questions:

• A Learning from Normal Work (LNW) Review process where teams get together and talk about how we do things, how Work-As-Normal has maybe drifted from Work-as-Written and what we need to change to get them aligned again,
• A Learning Study / Investigation process that gets to ‘lessons to be learnt’ in a meaningful way and includes processes for determining what the lesson looks like for various actors and what needs to be done to embed that lesson into Work-As-Normal.
• Verification processes that check up on how, and how effectively, lessons to be learnt are translated into behaviour changes and how sustainable the changed behaviour is across the business over time.
• Senior leaders’ language approach always asking ‘What can we learn from this?” and not ‘Who did this?’ after incidents
• A process that encourages and formalises the search for lessons to be learnt from other businesses, industries and countries and explores what the business can learn from them.
• Et cetera

What can we learn from this incident?

What internal experts do we need to get together to think about this?

What can we do differently?

What behaviours do we need to start, stop, or change based on this incident?

What systems do we need to create to show a culture where we don’t just share, we actually learn and change what we do?