Continual Improvement and Learning

Processes and structures need to be established to allow continual improvement and learning. Experimentation is an important part of the learning process, and trying new ideas and approaches to improving safety needs to be allowed and even encouraged. 

In addition, accidents and incidents should be treated as opportunities for learning and investigated thoroughly, as described in chapter 11. Learning will be inhibited if a thorough understanding of the systemic factors involved is not sought. 

Simply identifying the causal factors is not enough recommendations to eliminate or control these factors must be created along with concrete plans for implementing the recommendations. Feedback loops are necessary to ensure that the recommendations are implemented in a timely manner and that controls are established to detect and react to reappearance of those same causal factors in the future. 

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The nuclear engineering experience is not perfect, of course, but real strides have been made since the TMI wakeup call, which luckily occurred without major human losses. To their credit, an improvement and learning effort was initiated and has continued. High-profile incidents like TMI are rare, but smaller scale self-analyses and problem-solving efforts follow detection of small defects, near misses, and precursors and negative trends. Occasionally the NRC has stepped in and required changes. For example, in 1996 the NRC ordered the Millstone nuclear power plant in Connecticut to remain closed until management could demonstrate a safety conscious work environment after identified problems were allowed to continue without remedial action [34]. 

Education, not just training, with yearly reminders of the past, continual improvement, and input from lessons learned, trouble reports, and assessments during audits. 

Continuous Testing and Learning Improving the Signal to Market... 

Principles and ethics a set of principles for conducting a survey needs to be developed and adhered to. This might outline issues such as anonymity and confidentiahty, independence and impartiahty, respect for opiruons, robustness of methodology, continuous improvement, lesson learning, breadth of perspective, sustainable improvement, feedback to management and staff and follow-up support. 

The process and equipment documentation, as well as the operating and upset procedures, should create an archival history of the operation. In addition, while it is important to know the status of the operation, it is also important to be able to look back and learn from the operation s history to improve process safety continuously. 

Continuous improvement is a necessary element of a successful management system. Each investigation or implementation of the management system provides an opportunity to evaluate its effectiveness. The lessons learned strengthen and refine the management system. It is also valuable to recognize and share the positive aspects of those investigation activities that were especially successful. 

Analyze Weaknesses To learn from incidents, the final step is to recognize that the incident prediction and management systems are not perfect. Implementing practices to learn from mistakes and allowing continuous improvement to the systems to prevent incidents is essential. These practices are incident reporting and investigation processes. 

Proper investigation and documentation of near misses demonstrates that the company is behaving responsibly to learn lessons and continually improve risk management. 

This mode produces anxiety, fear, and disincentives to improvement among the production staff. This can set up an environment of high risk to quality and safety. Some aspects of this are further illustrated in section Drive cut fear that inhibits continuous. Learning curd improvement, and that which can increase risk . 

Pride of Workmanship and Continuous Learning Frequent corrective actions take away the pride of workmanship from production operators and other staff in industrial operations. In addition, FDA s penalty system (e.g., Warning Letters) is often construed to be directed at industrial operations. The ability to distinguish between common cause and special cause variability can be an important element in the FDA s penalty system and facilitate a move towards a continuous improvement approach and help build/improve the pride of workmanship dimension. 

Short-term profit volatility and analysts forecasts, then, have much less impact on a company s share price than is often assumed. Capital markets have a longer-term perspective. Furthermore, in an industry like chemicals, even if we assume a continuous improvement in fundamental performance, the attempt to generate an equally continuous, volatility-free growth in profits will be virtually impossible because of structural factors like feedstock volatility, currency exposure, and seasonal effects. Chemical companies should learn to live with earnings surprises and concentrate instead on communicating a concrete long-term strategy - and of course deliver appropriately on capital market expectations, which will be correctly set on this basis. 

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