A healthy safety management system implements a process for reporting, analyzing, improving, and learning from incidents.
Good safety leaders recognize that an open learning environment requires transparent reporting of incidents, understanding direct and system causes, and encourages employees to contribute their own ideas and experiences in finding solutions. Indeed, this method immerses the employees in their own work environment and permits them to take responsibility for their own safety within an honest reporting environment.
Employees with a vested interest in their own safety need to understand the context of incidents so that they can use the insights and apply them to their work environment. Communication of lessons learned should be shared with fellow employees in the form of case studies, workshops, and toolbox meetings.
Also, in order for communications to be effective, incident investigations must fully disclose the technical issues and root causes of near misses and accidents. Without full disclosure, the result is just surface learning that may not last. Company resources should be dedicated to thorough analysis of what went wrong and what needs to improve, including behavior-based safety. Near misses should be analyzed as much as the actual incidents, including anomalies, deviations, malfunctions, and other details that are easily overlooked. In addition, all incidents should be shared, not just the most serious ones.
Learning from incidents is personal; it should not be rushed or superficial. Employees learn from visual aids, video clips, procedure analysis, and technical discussions to make better sense of what happened and how to prevent it from happening again. Employees also learn from each other, especially from the people directly involved in the incident. When we share with each other, regardless of the mistakes made, we can then move forward to the most important part of learning, which is management of risk and the implementation of corrective actions.
Shared learning doesn't stop with awareness though. Each incident, including errors, complaints, and hazards, must be:
Reported and investigated in timely manner
Documented for compliance and future training efforts
Shared with all interested parties for safety culture improvement
For example, companies should provide an easy way to distribute learning from incidents to employees, such as an employee forum or company newsletter.
Employees must be encouraged to participate in shared learning efforts, from hazard reporting to willingness to address their own errors or mistakes. They must also feel empowered to recognize hazards and risks and to stop unsafe work when necessary. But most importantly, they should feel confident in communicating and sharing information, and be willing to learn and improve from shared learning findings.
Safework Solutions provides incident management software geared toward each process involved in shared learning, from hazard discovery and reporting to employee participation and overall learning distribution. Look for the Shared Learning tool in the Safework Suite®.
Reference: https://whatsthepont.blog/2018/05/30/the-james-reason-swiss-cheese-failure-model-in-300-seconds/
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