Using Lessons Learned

Lessons learned provide valuable information for managing health and safety programs. This information addresses conditions to be avoided or recommended practices. Lessons learned typically have the potential for wide-ranging application. Effective identification of lessons learned requires an awareness of emerging practices, programs, and technologies related to hazardous waste activities [3]. 

The safety alert concept is another tool that can be used by large or small businesses to communicate past best practices and indicate a path forward. On a daily basis, lessons learned should be communicated in a site safety meeting. A worker or supervisor may have discovered that a current practice could cause a potentially dangerous situation. Many times the correction or long-term fix for a hazard involves engineering 

The safety alert concept may also have a downside. Let s say that after an incident, the company management agrees that parts of the investigation and incident circumstances should be communicated to all workers in the company. After all, if we communicate the existence of a potential danger, we should be able to eliminate the injury in the future. To some, this is just common sense and can be considered a no brainer. However, at a later date, should another employee of that same company suffer a similar injury, what do you think the outcome might be The injured worker (or his lawyer) might be able to prove that the company was negligent because it knew of the problem (as shown in the safety alert) but failed to adequately address it. 

There are at least a couple of conclusions we should draw from this example. If you are going to use safety alerts, even though your intentions are honorable, you may offend the injured party, the folks who took part in the investigation, and others. Be prepared for the fall-out. Also, keep in mind that you need to talk the talk and walk the walk. If an incident occurs and a corrective action is indicated, it behooves you to implement some level of corrective action. If you do not implement a sound corrective action, your company likely has an ineffective safety program to go along with a variety of outstanding lawsuits. 

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  

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Kaizen— A quality system using lessons learned... 

The SunLine Transit Agency [50] (in Thousand Palms, California) has demonstrated in service several FCB architectures (Figure 9.8), using lessons learned to improve... 

Use lessons learned from both the PSSR successes and setbacks your facility or industry experiences as events worthy of evaluation. These can help determine which programmatic aspects work - and which aspects don t work - in your PSSR management system. 

Most often, however, companies tend either towards local responsiveness or to strong global standardisation and organisation. Hewlett-Packard used to be in the former camp. At one point, for example, the company found that there were dozens of similar B2B exchange efforts under way across the company with at best informal coordination between teams. HP did not respond with a centralisation of efforts and control. Instead, it developed a distributed governance approach that allows for local responsiveness, but that also uses lessons learned for the company and avoids duplication of efforts. 

Crossley, I A, Valade, M T and Shawcross, J (2001), Using lessons learned and advanced methods to design a 1,500 ML/day DAF water treatment plant . Water Science and Technology, 43(8) 35-41. 

Lessons Learned. It s very early in the game to make predictions about what changes may be needed as a result of the Manwood test. However, there are already some useful insights that the Task Force expects to factor into the PSM installation plan for the division. These include 1) We need to be very clear in introducing PSM to our employees, and take time to answer their questions. Orientation meetings should be at least 90 minutes, not the one hour we had scheduled. 2) Getting valid feedback takes some effort personnel need to know we mean it when we say we want constructive criticism. 3) Close collaboration between the Task Force and the facility manager is absolutely vital. 

This indicates that error management comprises two strategies proactive methods are applied to prevent errors occurring, and reactive strategies are used to learn lessons from incidents that have occurred and to apply these lessons to the development of preventive measures. Both proactive and reactive methods rely on an understanding of the courses of human error based on the theories and perspectives presented in this book. The tools and tech-... 

This report evaluates recent performance of DGs and all DG vendors with the exception of Transamerica Delaval, Inc. (TDl), because of the emphasis already being given to TDI diesels in other studies. For the period 1980 through 1983 inclusive, BNL reviewed and evaluated DG failure data, DG vendor inspection reports, the TDI lessons learned as they related to the other vendors, and previous pertinent studies. The data sources used for DG failure analysis were LERs, 10 CFR 50.55E, Part 21, NPRDS, and EPRI document files. The DG failures were classified relative to the DG component that failed (e.g., main bearings, starting system). The failures were also categorized and analyzed by mode, manufacturer, and cause. Manufacturers with significant failures are identified in the report. 

Esterases have a catalytic function and mechanism similar to those of lipases, but some structural aspects and the nature of substrates differ [4]. One can expect that the lessons learned from the directed evolution of lipases also apply to esterases. However, few efforts have been made in the directed evolution of enantioselective esterases, although previous work by Arnold had shown that the activity of esterases as catalysts in the hydrolysis of achiral esters can be enhanced [49]. An example regarding enantioselectivity involves the hydrolytic kinetic resolution of racemic esters catalyzed by Pseudomonasfluorescens esterase (PFE) [50]. Using a mutator strain and by screening very small libraries, low improvement in enantioselectivity was... 

Gillespie HA, Moke P, Beck R, Lester LA. Lessons learned in using web-based randomization in the community-based amblyopia treatment study. Controlled Clin Trials 2001 22 2S-80S. 

The Physiome Project will undoubtedly benefit from lessons learned during the progress of the Genome Project, in particular, that big visions and small steps (at least initially) are not necessarily a contradiction. It will, however, have to develop a completely different approach to problem solving than that used for the Genome Project, as neither the total dimension of the task (there are only 23 human chromosome pairs) nor the size of the smallest component that needs investigating (DNA bases) can be defined at the outset of the Physiome Project. 

In many respects, crop production has advanced little in the last two decades. More tools (herbicides and insecticides) are available for use by producers, but in many cases we have not fully utilized lessons learned earlier. Residue management seems to be one of those cases. In no-till agriculture, residue management techniques will have to be developed—by engineering, chemical, or biological means—for the system to function. 

This work is not an attempt to look at the past and future of the pesticide problem from the environmental point of view. After the general discussion of pesticides properties and use in the USSR (Chapter 1), we look successively at the unexpected consequences of pesticide use, for the natural environment, humans, and for agriculture itself.This work concludes with Lessons Learned from Pesticides, food for thought for policymakers, ecologists, and farmers. 

A number of optical chemical sensor systems have been developed for food and packaging applications and proven their utility. Some sensors, such as phase-fluorimetric oxygen sensor, have already reached high degree of maturity and demonstrated their potential for use on a mass scale. While the others still require extensive research, development and search for new solutions, so as to match basic practical requirements for such sensors. The experience and lessons learned with current optical sensor systems must be... 

The lesson learned from the catalysis in interphase approach is that the spacer between the insoluble support and the actual catalyst should be sufficiently long and soluble in the solvent of interest to obtain active catalysts. The use of supercritical fluids can also be very beneficial for the activity. Upon using Xantphos immobilised on silica in scC02 for example, the rates are only half of those of the homogeneous catalyst. Expressed as space-time yields the solid catalysts are almost an order of... 

Use the paper developed by the EPA (see footnote 27) to describe the lessons learned as a result of the phenol-formaldehyde runaway reactions. 

This thesis is focused on the pro-active Sis in order to derive pre-accident warning signs and reactive Sis will not be addressed. However, this does not mean that the reactive Sis have no use as pre-warning signs. On the contrary, they contribute to the enhancement of the pro-active Sis by means of the lessons learned from accidents. 

PSCMS is primarily designed as a metric for tracking industry performance on process safety incidents it is not intended to be a lessons-learned database. However, if expanded to include causes and lessons learned and if more widely distributed, the data could be useful in preventing similar incidents. 

The EDS II test program for the 12-kW SILVER II plant involved the operation of two campaigns, the first to destroy Composition B and then a mixture of Composition B and M2 8 propellant and the second to destroy the agent simulant dimethylmethylphos-phonate (DMMP). For the EDS II tests, the 12-kW plant used in Demo II tests was upgraded to incorporate lessons learned from Demo II and demonstrate proposed solutions for problems that were encountered during Demo II. A summary of EDS II tests using the... 

This chapter focuses on the value of critically analyzing incident information and discusses the benefits of using databases to evaluate lessons learned. The power of both internal databases and industry-wide incident databases can help organizations improve their performance in process safety and environmental responsibility. 

Investigators can systematically analyze data from past incidents to identify lessons learned and develop incident stereotypes. This makes it possible to develop a model displaying the anatomy of a process-related incident using a conceptual framework. Figure 3-1 provides a tool to help us understand incident causation. 

Historical incident recording and communicating in useful form has several beneficial results. This information suggests precautions for other facilities, allows lessons learned to be taken into account in future design, and helps identify trends not apparent from single incidents. Because... 

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