Lesson dissemination

Lesson dissemination. An organisation should ensure that lessons learnt from its safety assessments, hazard logs, safety occurrence investigations, case histories. 

Incident investigations are a part of process safety management. In investigations, lessons are learned as to how inherently safer technology could have prevented or mitigated the results. How can these learnings be disseminated such that future incidents in similar processes are avoided ... 

Exactly what type of lessons are learned cannot be foreseen. The size and diversity of site activities give rise to a wide variety of health and safety hazards. Individual sites need to document and disseminate information that could enhance their hazard recognition and mitigation. Effective documentation is an important concept that everyone needs to buy in to if the safety program is going to be effective. Wliy workers fail to document potential problems has been the subject of much debate. 

Much effort has been (and continues to be) expended to plan the closure of JACADS in advance and in great detail, and much will certainly be learned in the course of closure operations and facility closeout. With eight continental U.S. sites for disposal of the remaining U.S. chemical stockpile now operating, under construction, or planned, significant economies in time and cost associated with their eventual closure may be obtained through careful and timely dissemination of the lessons learned from closure activities at JACADS. 

A high premium should be placed on capturing and disseminating lessons learned from JACADS closure. To the extent possible, other disposal sites could incorporate applicable JACADS experience in their original permit applications or in early permit modifications doing so would help avert indecision and potential schedule delays and additional cost impacts associated with late permit modification development and processing. 

Nurses and other health care providers can assist in preventing heat-related illnesses and deaths by disseminating community prevention messages to persons at high risk (e.g., the elderly and persons with preexisting medical conditions) using a variety of communication techniques. They may also establish emergency plans that include provision of access to artificially cooled environments. Case Study 17.4 describes a case of mortality and the lessons learned in a heat wave in Milwaukee in 1995. 

There is a good deal of pubhcly available information concerning incidents that can be of value to all facilities and plants. The public dissemination of accident and incident histories will help all companies improve their safety. For legal reasons, it may be necessary to change some of the information to protect individuals and to keep sensitive industrial information secret, but changing the information in this way is not likely to change the value of the lessons learned. 

Many people use stories to develop root causes by analogy. They examine incidents that have occurred elsewhere and develop lessons that can be used in the current situation. Indeed, many companies encourage the dissemination of incident stories in order to create a lessons learned culture, and some professional organizations publish information to do with incidents that can be used by other companies. For example, the journal Chemical Engineering Progress routinely publishes descriptions of actual events. 

Significant safety data representing lessons learned are to be documented and disseminated to interested personnel. 

Tabulate and disseminate lessons learned and incorporate those lessons for future safety enhancement. 

In order to produce believable RACs or any other quantitative risk assessment, reliable, valid data are required. Even though considerable data exist, they are not necessarily available or in the correct format. Improvements can be made in the sharing of lessons learned, mishap information, reliability data, and the other information needed to support the system safety effort. A well-organized effort to identify and catalog existing databases and to develop plans for the systematic collection and dissemination of new data would benefit the entire safety community. 

Literature distribution service. Hospital librarians can create a literature distribution service so that key lessons reported in the literature and inside the organization can be disseminated to employees working on particular areas of concern (Williams and Zipperer, 2003). 

The hospital librarian can also be engaged to establish a knowledge map outlining where safety expertise lies within the organization. The librarian can serve as a human bridge between the sharp and the blunt end to improve transparency and help disseminate safety lessons (Zipperer, Gluck, and Anderson, 2002). 

Case studies, to spread lessons learned and alert others to risks experienced, should be brief (no more than two pages) and communicate key hndings from analysis of accidents, near misses, or hazardous conditions to help inform safety within an organization and beyond. Events external to the organization can also be imported and disseminated if the lessons learned have the potential for application. 

Case studies of lessons learned and system changes should be routinely communicated internally after a significant or sentinel event and need to meet rigorous standards of confidentiality. The case studies containing lessons learned should be construed for dissemination beyond the organization as well. Therefore, aU case studies must be de-identified. 

The Club brings together technical and managerial personnel within all sectors of the safety-critical-systems community. Its events provide edueation and training in principles and techniques, and it facilitates the dissemination of lessons within and between industry sectors. It promotes an inter-disciplinary approach to the engineering and management of safety, and it provides a forum for experienced practitioners to meet each other and for the exposure of newcomers to the safety-critical systems industry. 

The evaluation process needs to include the dissemination of information and the lessons learnt, to the relevant response organisations. This will include any recommendations arising from the testing and the progress of actions. 

A complementary approach to disseminating the knowledge and experience of Member States is to provide the lessons learned directly. The occurrence and recurrence of events, deviations from current international practice in design and operation, and results of PSA studies allow valuable insight into weaknesses in plant safety and into corrective measures to resolve them. 

The timely dissemination of information on structural failures has long existed in the pages of Engineering News-Record, which is proud of its 110-year tradition of reporting and recording. While no one claims the back issues of ENR to be any official archive of failures, they certainly are a treasure trove, and the recently published book Construction Disasters by Steven S. Ross is an attempt to categorize some of the contents of that trove and to draw some lessons out of it. 

Analyze all incidents and disseminate lessons learned and good practices based on shared experience among its all members... 

Operator investigates all near misses, incidents, and accidents, and then identifies lessons learned and disseminates them to personnel within the company/organization, other operators, risk management commimity, and inspectors... 

Commission (or other independent body) performs analysis of accidents and then disseminates the lessons learned... 

The feedback of operating data or experience is an inherent and important aspect of NRC activities and involves all NRC organizational elements at one time or another. The principal NRC organizations involved are the Office of Nuclear Reactor Regulation (NRR) and the Office for Analysis and Evaluation of Operational Data (AEOD). AEOD was established several months after the TMI-2 accident to identify and feedback significant safety lessons of operational experience to the NRC, its licensees, the nuclear industry as a whole, and the public. Table 2.2-5 lists some of the NRC-originated documents that are used to disseminate relevant nuclear power plant experience. Of particular interest to licensees are Bulletins, Information Notices, and NRR Generic Letters. 

---