August 28, 2019 | Mark Paradies

Lessons NOT Learned

Lessons Learned – Lessons NOT Learned

When you have an accident, you should learn from the errors that were made so that you don’t repeat them.

If you have an incident that could have been much more serious (a precursor incident), you should learn lessons that will prevent a major accident in the future.

Every major accident I’ve ever studied has had many precursor incidents.

So, here is the question:

Why didn’t they learn lessons from the precursor incidents
to prevent the major accident?

Why Are Lessons NOT Learned?

Most failures to learn lessons are due to three main causes:

  1. Poor root cause analysis
  2. Poor development of corrective actions
  3. Failure of management to get improvements implemented

Of course, there can be other causes. For example, there can be a failure to identify and investigate precursor incidents. Although you may look at this type of failure as poor root cause analysis too.

How do you fix these three types of learning failures?

  1. Adopt an advanced root cause analysis system with proper documentation and continuous improvement.
  2. Make sure your root cause system helps investigators develop effective corrective actions.
  3. Implement fixes in a timely manner and audit fixes to make sure they are implemented and effective.

That seems pretty simple.

Do You Have Lesson NOT Learned?

Every time your company experiences a major accident, they have also had another problem. They have one, or more likely many, precursor incidents that they DID NOT learn from.

That brings me to a major point in this article. If you have a major accident, do you ask the question:

Why didn’t we learn from our precursor incidents?

The answer to this question can identify problems with your current root cause analysis / corrective action / implementation systems.

Identifying and fixing these problems is an important part of stopping future accidents.

Imagine the lives and/or money that could have been saved and the environmental damage avoided if these accidents (some historic, some less remembered, from all over the world) had been prevented:

  • The Vale Brumadinho Mine Dam, Brazil, collapse in 2019
  • Camp Fire in Paradise, California, in 2019
  • The Fernie Memorial Arena, Canada, ammonia accident in 2017
  • The Aliso Canyon Gas Storage Facility failure in 2015
  • Port of Tianjin, China, warehouse explosion in 2015
  • West, Texas, fertilizer plant explosion in 2013
  • The sinking of the Costa Concordia in 2012
  • The San Bruno Pipeline explosion in 2010
  • Upper Big Branch Mine explosion in 2010
  • The Deepwater Horizon accident in 2010
  • The Sayano-Shushenskaya Dam, Russia, failure in 2009
  • BP Texas City Refinery explosion in 2005
  • The Columbia Space Shuttle breakup during re-entry in 2003
  • The AZF Fertilizer Plant, France, explosion in 2002
  • The Enschede, Netherlands, fireworks explosion in 2000
  • The Concord Jet crash, France, in 2000
  • The Ladbroke Grove, UK, railroad crash in 1999
  • The collapse of Big Blue Crane in 1999
  • The DeBruce Grail Elevator explosion in 1998
  • The Exxon Valdez oil spill in 1989
  • The Bhopal, India, chemical release in 1989
  • The Phillips Pasadena explosion in 1989
  • The Piper Alpha oil platform fire in 1988
  • The Chernobyl nuclear accident in 1986
  • The Challenger Space Shuttle explosion during launch in 1986
  • The meltdown at Three Mile Island in 1979
  • The Seveso, Italy, explosion in 1976

This is just a fragment of deadly, expensive accidents that could have been prevented. These accidents remind me of the “How Far Away Is Death” pictures that we publish. The pictures are precursor incidents that have been captured in a picture. The questions that I think about are …

Did anyone learn anything?

Will future accidents, like those above, be prevented?

Learn to Learn Lessons

Don’t wait for a major accident to learn lessons. Attend a TapRooT® Root Cause Analysis Course where we teach advanced root cause analysis to learn from precursor incidents to help you prevent major accidents.

When and where are the public TapRooT® Courses being held? Here are a few 2019 courses being held around the world in the next few months (presented in English unless otherwise noted):

For a complete list of locations and dates, see:

https://www.taproot.com/store/Courses/

Categories
Accidents, Root Cause Analysis Tips
Show Comments

2 Replies to “Lessons NOT Learned”

  • David Hanning says:

    Have you ever considered applying TapRooT principles to the epidemic of mass shootings in your country? Not many lessons being learned there…
    – Poor root cause analysis
    – Poor development of corrective actions
    – Failure of management to get improvements implemented
    I would submit all apply?

    • Mark Paradies says:

      Yes

      But I find the issue tremendously political and there is a lack of accurate publically available information.

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