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Learning from incidents, accidents and events

Learning from incidents (LFI) is a process whereby employees and organisations seek to understand any negative events that have taken place and then take actions in order to prevent similar events from happening again. Developing an effective process for LFI will provide an organisation with a critical tool for managing its risks. Inadequate LFI processes have been cited as contributory factors in major accidents such as the space shuttle accidents, Piper Alpha, Macondo and many others. An effective LFI process will use multiple opportunities for learning to optimise changes that lead to a lower risk, more stable, business environment.

learning from incidents accidents and events

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Price: Free
ISBN: 978 085 293 9 277
Version: 1st (August 2016)

The Learning from incidents, accidents and events publication covers the whole LFI process, from reporting and finding out about incidents, through to implementation of effective learning and resulting in changing practices. As a comprehensive resource for LFI, it provides good practice guidance for all key phases of the LFI life circle and places importance on learning in addition to accident/incident investigation. It guides the reader to understand the human and organisational factors (HOF) causes of an incident through appropriate investigation approaches.

It should be noted that this publication covers all elements of the lifecycle below, so it includes guidance on reporting, investigation, communicating, reflecting, and embedding learning.

Further resources

The Energy Institute and other organisations publish lots of useful information on learning from incidents.  The below resources have been mapped to the 'learning from incidents lifecycle' (those available from the Energy Institute are shown in the image as examples).

General information (including organisational learning)

The following resources cover general information about learning (from incidents or from normal work):

An incident occurs...

These resources include databases of incidents (incident alerts etc.), and guidance on incident response:

  • - Toolbox: a free web-app sharing lessons learned with frontline workers. Contains over 500 high quality incident alerts, including videos, suitable for sharing with teams, in 10 languages. All are good examples of incident alerts.
  • - CCPS, More Incidents That Define Process Safety -  provides information on dozens of process safety incidents, covering fires, chemical hazards and other process safety hazards.
  • - Energy Institute, Investigation insights - Tool 1: A leader’s role: this tools focuses on how leaders respond to incidents, including in the aftermath, but also in setting the investigation up for success.

Reporting

Reporting of incidents is necessary for them to be learned from. The following resources include guidance on creating a ‘psychologically safe’ environment where people can freely report incidents, and ways to capture information in reporting systems:

Investigation

During investigations, incidents and other events such as near misses are analysed, and the various causes identified – including failed barriers, human actions (mistakes and non-compliances), performance influencing factors/preconditions and underlying causes. In short, the investigation finds out what happened, how it happened and why it happened. The following resources include investigation methodologies and guidance for investigators and others involved in the investigation:

Developing incident alerts

‘Incident alerts’ are usually short one-page documents, videos or other learning materials that can be shared with people following an incident investigation. The following resources are good examples of incident alerts, and guidance on how to create incident alerts:

  • - Toolbox: a free web-app sharing lessons learned with frontline workers. Contains over 500 high quality incident alerts, including videos, suitable for sharing with teams, in 10 languages. All are good examples of incident alerts.
  • - Energy Institute, Hearts and Minds, Learning from incidents: provides exercises to help you create engaging incidents alerts.

Communication

It is critical to communicate lessons learned from incidents with the right people and in the right way. The following resources can help:

Reflective learning

Adults learn through ‘reflective learning’. This means that people need to be given the time and space to really make sense of an incident alert, and reflect on what it means to them and their job. The following resources include more information on what reflective learning is, and examples of reflective learning materials:

  • - Energy Institute, Hearts and Minds, Learning from incidents: includes exercises to help do reflective learning sessions with teams.
  • Video: Energy Institute, Reflective learning: this short video introduces the concept of reflective learning, and tips on how to do it.
  • - Energy Institute, Reflective learning videos: 9 videos on topics including barrier management, line of fire, dropped objects and contract management. Each video includes a facilitator guide. These are good examples of reflective learning materials.
  • - Toolbox: a free web-app sharing lessons learned with frontline workers. Contains over 500 high quality incident alerts, including videos, suitable for sharing with teams, in 10 languages. Every incident alert includes reflective learning questions (‘Ask yourself or your team’).
  • - Energy Institute, Investigation insights - Tool 3: Better insights: a robust workshop exercise to help leaders and other understand an incident, its causes, the role they played, and improve recommendations.

Implementing actions and measuring outcomes

Learning can only be said to have taken place is there is a change in processes, documentation, behaviours etc. The following resources can help implement actions from investigations, and measure effectiveness: