Lesson sharing Lessons learned

Share lessons learned and help provide approaehes that have been implemented on hazardous waste and other sites... 

There is no publicly available database for sharing lessons learned from reactive incidents. 

Formal acceptance of recommendations Assignment of a responsible individual Determination of action priority Implementation of actions Changes to the management system Audit trail Action tracking Sharing lessons learned Follow-up audit Incident trend analysis... 

Reduce learning curves and share lessons learned... 

The following individuals and companies are acknowledged for their contributions Patrick Foley (Senior Environmental Engineer, U.S. EPA), for his input and permission to use information and data. EPA ECC Technical Team Members, for team participation and willingness to share lessons learned in Consent Decree implementation. 

Share lessons learned and training materials with Health Canada, MHLW, and EMEA... 

Here is the CEPPO s mission statement EPA s Chemical Emergency Preparedness and Prevention Office (CEPPO) provides leadership, builds partnerships, and offers technical assistance to prevent and prepare for chemical emergencies respond to environmental crises inform the public about chemical hazards in their community and share lessons learned about chemical accidents. ... 

CaFCP and its members plan to work together to help prepare local communities for fuel cell vehicles and fueling by training local officials, facilitating permit processes and sharing lessons learned. The CaFCP and its members also plan to promote the development of practical codes and standards for FCVs and fueling stations, and help to obtain financial and other support where needed. 

Incident Tracking and Analysis Database of incident information Periodic review of data Identification of trends in data Share lessons learned internally and, as appropriate, externally Proactively involve all parties to prevent future occurrences... 

Systems are in place to share lessons learned from incidents and near-misses, trends, and successful practices across the company. These interact with others as appropriate and benchmark best practices to facilitate improvements in performance ... 

We envision a time in the near future when regulators and internal teams under siege will be replaced by expert teams assembled from multiple sciences to conduct external reviews of health care accidents and near misses in pursuit of high reliability. These teams will share lessons learned publicly and end forever the conspiracy of silence. And no longer will valuable learnings be lost to combat the epidemic of our time medical accident. After all, if lethal medical accidents can occur in our best institutions, accidents can happen anywhere, and no organization is immune. 

GAO (Government Accormting Office). 2002. Better Mechanisms Needed for Sharing Lessons Learned, GA-02-195, January 30, 2002. Washington, DC. 

Very active internationally at safety conferenees to share lessons learned and promote better safety results for all. In fact, they benchmark their safety performance and share best practices at various international forums. 

Share lessons learned and accident results to all employees so that they know how it was resolved and will be prevented in the future. 

Are there traditions and systems for the detection and blame-free exploration of biases and errors, and for sharing lessons learned These cultural attributes and practices are fostered by a strong transformational leadership style (see chapters 4 and 5) and reflected in high scores on the OCDI s four organizational dimensions (procedural justice, perceived organizational support, leader-member exchange, leadership credibility). 

Set high, specific standards for continuous improvement of critical OE processes. Share lessons learned and seek out and adopt processes that could improve performance. 

All employees and contractors Operate incident free Participate in OE processes and recommend improvements Share lessons learned Investigate incidents share causes Undertake OE principles... 

It is good practice to reviewa project on completion and record the reasons for departure between planned and actual performance. Where lessons can be learned, or opportunities exploited, they should be incorporated into project management guidelines. Some companies hold post project sessions with their contractors to explore better ways of handling particular issues, especially when there is an expectation of additional shared activities. 

In the DOE environment, the term lesson learned is defined as a good work practice or innovative approach that is captured and shared to promote application. It may also be an adverse work practice or experience that is captured and shared to avoid recurrence. This term is used by DOE and other federal and private-sector institutions, to describe the following ... 

Tlie DOE Office of Environmental Safety and Health distributes monthly summaries ba.scd on data retreived from the DOE Occurrence Reporting and Processing System (ORPS) to share chemical safety concerns throughout the industry to alert operators of similar processes. In addition quarterly and annual reviews feature lessons learned from ORPS by trending analyses of ini an... 

Question 5 Is the controller/switcher IC at fault (by design) This is actually a fairly common occurrence. No semiconductor product is released without its fair share of shortcomings. These are usually known to the company at the time of release, with the internal understanding that there were some lessons learned, and these will be resolved when the time comes for the next Rev, or the next product. Fair enough But there are several variations to this theme, some that you may need to be aware of as you seek answers to a particularly stubborn problem. The three main variations are that the company knows about the problem the company knows about the problem but does not want to admit it or the company does not know about the problem. 

Information related to broader industry issues, newly recognized hazards, and lessons learned from near misses and actual incidents can also be shared with customers and users as part of product stewardship. Trade, professional, and other cooperative organizations such as universities and local emergency planning committees (LEPCs) can be effective vehicles for information sharing, in addition to individual company initiatives. 

It strongly supports reporting and investigating incidents and near misses, and emphasizes the value and necessity of communicating and sharing the lessons learned to all that could benefit. 

---