Sharing Lessons Learned

The effectiveness of communicating important lessons across organizational boundaries is critical to the success of any investigation. A management system should be in place to ensure that the understanding of the lessons learned is not isolated to a single location. The challenge of main- 

Some companies have found success with a periodic publication of incident abstracts. Each incident may appear as a one- or two-paragraph summary in a quarterly bulletin. This information should be circulated widely within the corporation. If a site has a special interest in one particular incident, then full details can be requested by direct contact between the two sites. The highly abbreviated summary has other uses for instance, as material for employee safety training meetings or bulletin board postings. 

CCPS sponsor companies may subscribe to a confidential database of accident case studies and causal data. Any operating company prepared to submit and share incident data may subscribe to this Process Safety Inci- 

The following references provide information on techniques for sharing of lessons learned as well as additional information on some of the case studies that were highlighted in this chapter. Other significant incidents are also cross-referenced in some of these documents. It is important to recognize that some of these publications have heen written from a nontechnical perspective and may not have recognized the concepts or methods covered in this text. 

American Chemistry Council. Responsible Care , A Resource Guide for the Process Safety Code of Management Practices. Washington, DC 1990. 

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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... 

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