Accidents and Incidents - backward control of unwanted events
Accidents, incidents and other type of
unwanted events and their losses are an excellent source to improve the management system and further control loss.
The reasoning behind this is that – in principle – all unwanted events can be prevented and they all originate from
the management system.
Unwanted events such as accidents, errors, mistakes, omissions, oversights, etc. - are good
sources to learn from
and to take steps to make sure that the
same or similar will not happen again.
Learning from accidents and incidents
and other unwanted events
from unwanted events requires:
what happened - register facts for communication and cause analysis
why it happened - carry out cause analysis
why the consequences were what they were - evaluate post event actions
out remedial actions - make sure they will be done well and on time; assign
others know - communicate and report so they will learn as well
to have a system similar to what is described in an accident investigation protocol. The protocol
describes the process to learn from unwanted events such as accidents, incidents, complaints,
Learning from No-Loss events
Learning from accidents with relatively minor
consequences, or no consequences at all, is a better way to learn ... but you need to have a risk classification system to make them important. So
that resources will be made available to investigate, analyze and take remedial actions.
Risk classification could also be used when
evaluating deviations noted during inspections or behavior observations. If fact, the substandard acts or
conditions observed could result in loss .... if the circumstances would have been different.
From accidents to the management
While learning from accidents covers all
aspects of the accident causation model, the real learning that will prevent similar events to happen again -
possibly with a much greater impact - accumulates in the area of the management system , its work processes and related
procedures, work methods, etc.
is in the management system that the experience from unwanted events comes together to further improve the system -
the organization's "memory" and the "way we work" - to prevent unwanted events and their consequences in the
future: Learning From Accidents.
Learning from unwanted events accumulates in
the management system giving direction to procedures and instructions and determining how work places and installations
are to be designed and equipment is to be purchased. How work procedures are to be set up and people are to be
trained to properly, safely, carry out their work. This way the management system, by
creating a better
working environment and better communication, helps to mold the culture of the organization while at the same
time obtaining better cost control and sustainable profitability.
Should you investigate all minor or no-loss events?
I do not think so. You want as
many as possible reported and you want to record them for trend evaluation and you want to know what these small
losses cost you per period.
After they have been
reported, recalled or imagined, use a risk classification tool to
find the high potential (HIPO) events that could lead to serious loss and carry out a cause analyses on
Be aware: giving too much
attention to events that will not and cannot generate important losses may lead to demotivation of people,