Guidance on Learning From Incidents, Accidents and Events

A number of industry commentators have noted that the energy and allied industries still need to impro ve in learning lessons from incidents. Partly this view i s prompted by the reoccurrence of similar events, a nd partly by anecdotal evidence of the difficulty of achievin g long term changes in behaviour and working processes, when sharing lessons from accidents and incidents. Previous research has indicated challenges at sever al stages in the Learning from Incidents (LFI) proc ess including: • Reluctance to report incidents due to fear of disci plinary action or the perception that reporting doe s not lead to any change • Lack of human factors expertise in the analysis of incidents • Lack of time and resources dedicated to helping peo ple understand and make sense of disseminated lessons • Overload of recommendations and failure to agree actions with all the involved parties • Failure to check that implemented changes have addressed the underlying causes and reduced risk. The Energy Institute (EI) published in 2008, ‘Guida nce on investigating human and organisational facto rs aspects of incidents and accidents’. This provides guidance on ensuring human and organisational factors are considered in addition to technical causes when inv estigating incidents, and has been well used in the industry. Most companies have now implemented formal tools and techniques for identifying why an incident happen ed. In recognition that the next emerging challenge fac ing the industry is about learning from, and changi ng after, an incident, the EI’s Human and Organisational Fact ors Committee (HOFCOM) was asked by the EI’s Technical Partner Companies (comprising many of the major energy companies) to update and broaden the original 2008 guidance document. It will now cover the whole LFI process, from reporting and finding out about incidents through to effective learning and c hanging practices. The LFI guidance is being produced with the help of a series of industry stakeholder workshops organis ed by the EI and will act as the initial ‘go to’ resource for LFI. It will inform on good practice for all key phases of the LFI process, and will draw upon existing materi al and use the outputs from the stakeholder worksho ps at which LFI experts have contributed their experience , examples and case studies. This will help to ens ure that the guidance document will be suitable for LFI prac titioners. This paper describes the background to the development of the updated guidance document and provides an overview of its contents. This will include a step by step guide to LFI and a summary for managers of the key issues associated with LFI.