Despite the advances in understanding safety the accidents are still recurring. Thus the question arises “why don't the organizations learn from past accidents and why do they continue to fail by making errors and ignoring rules”?
It is widely accepted that the industries that fail to learn from past accidents can observe many things to go wrong where a designer or operator is hardly aware of things that may go wrong. Accidents/ incidents are often repeated events that are almost similar in nature to the earlier incidents. Accidents reveal many facts and thus present realistic opportunities for the organization to learn lessons which will not only help in preventing the recurrence of the same kind of accidents but can also enable them to improve the safety performance and establish a total safety culture. Many of the accidents are preventable only if we understand how and why they happen. Learning from past accidents and incidents can be promoted by overcoming the barriers such as blame and fear of reporting and establishing a culture of reporting accidents, near misses, unsafe acts and conditions.
Learning from incidents (LFI)
An effective process of learning from incidents is critical for a safe working environment. LFI can enable the organizations to gather knowledge about what went wrong in the past (events, accidents, near misses) and change working conditions/ practices to prevent future incidents. But without a proper understanding and learning process or a management that fails in engaging the workforce effectively can put the organization at risk of repeating the same incidents with the similar causes.
Understanding the accident is not as easy. It needs patience, commitment together with skills and competence in order to balance competing inspection. There is a need for managers, safety professionals and workers to develop a more knowledgeable and advanced approach of understanding the complexity of the accidents. This includes the technical factors, system failures and human factors (especially human errors such as lapses, mistakes, absent mindedness, carelessness, and violations) as we all often hear in safety “Most of the accidents are caused by human error”.
While learning from accidents it is important to understand that only the physical or direct causes of the accidents are focused but also the other contributory causes such as the management factors (i.e. the root causes including lack of management or system control) that is explained by domino theory of accident causation.
The domino theory explains that accidents are caused by a series of factors. An organization must not only address the direct or immediate causes but also the root causes that prevent the future accidents. However, the root causes are often associated with lack of safety adequacies like policies, culture, commitment that seems to be more challenging for the organizations.
Learning from incidents helps acquiring knowledge and skills from a thorough study of accidents and their precursors. It is a structured process that involves:
Gathering information on abnormalities, deviations, near misses, incidents and accidents.
Analyzing the sequence of events and their causal factors
Extracting new knowledge or learning from the analysis
Implementing corrective actions or action plans
Sharing the learning within the organization
Recording the learning so that it can help in the future
Future actions for accident prevention
It’s important to consider two things in order to learn from the incident and prevent the similar accident happening.
Find the underlying causes of the accident.
Address the root cause to prevent the recurrence of the accident.
Therefore, these questions has to be addressed
1. How to prevent a similar accident occurring with the existing conditions/ processes?
2. How to ensure the future changes / modifications did not cause similar accidents?
Therefore, organizations need strong safety policies and procedures to establish safety culture and aim for accident prevention by also learning from past accidents. In summary, learning from past accidents can prevent future incidents but failure to understand the complexity of accidents can lead to future accidents.
Article by Dr.Yashoda Tammineni,
MSc, Ph.D.
HSE,HOD at NIFS
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