Root Cause Analysis Tip: Lessons Learned
This week I would like to talk about lessons learned – Appendix C.13 in the TapRooT® Book.
Since the point of investigations is to prevent recurrence, it makes sense to have a process that communicates in a way that achieves maximum benefit from investigation efforts. Unfortunately, many organizations do not collect and distribute lessons learned.
So why don’t organizations communicate with other parts of the company? Because it takes effort, thought, but most of all, a PROCESS. As Mark Paradies and Linda Unger point out in C.13, the effort required to put together a lessons learned process pales in comparison to the effort it takes to investigate multiple accidents caused by the same things.
My first recommendation is to make sure your company has an internal lessons learned program. This is a formal way to send out information gathered through investigation efforts. You have to decide the communication medium, the distribution channels, and the format. Small companies may be able to communicate lessons learned face-to-face, while larger ones might have to rely to a greater extent on written communications. Every organization is different. The key is to document a process that can be consistently applied in your environment. If you use written communications, you want to use things that grab the reader’s attention, like pictures, cost of the incident, or extent of injury or business disruption. A good document can be used as talking points for supervisors in face-to-face communications, and posting or distribution in larger operations. You should also make sure any changes to policy/procedure/training are made as it relates to lessons learned.
So now that we have talked about internal lessons, what about external ones? How do you collect information from outside your company? There are many ways, such as industry or discipline groups and conferences as well as electronic media. Some regulators have very good websites that can provide information on both regulatory changes and incidents that have occurred elsewhere. Search engines also can provide automatic news directly to your e-mail to monitor industry trends. Most industries and disciplines have newsletters that you can subscribe to for free or a nominal fee. You can also benchmark other companies. If you do an effective job of monitoring industry issues, you can incorporate lessons learned into your programs before you experience some of the problems of your peers.
One thing I do want to mention before I close – most companies have a tendency to benchmark within their industry, and that make perfect sense. However, many times the best lessons learned come from outside your industry, so consider that, especially if you are already at the top of your particular industry. One of the best places to get cross-industry, cross-discipline exposure is the TapRooT® Summit. I don’t know of another conference where so many different industries and disciplines come together. Equipment reliability people from oil and gas can network with safety people from manufacturing, environmental people from transportation, and regulators from different countries. You get the idea. So why not plan to join us in 2012? The next Summit will be held in Las Vegas, Nevada, February 29-March 2, 2012. Mark your calendar and keep an eye out for details on this weblog.
Thanks for visiting the blog today, and best of luck with your lessons learned.