Learning from Accidents: Are we asking the right questions?

Gill Kernick's picture
Gill Kernick, Senior Consultant, JMJ Associates
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A sense of curiosity and asking some different questions offer an opportunity to impact our chronic inability to learn which typifies the ‘awful sameness’ of accidents. 

We are in a vicious cycle – there is an accident/near miss/HIPO. We investigate. Analyse. Produce Reports. Highlight failures to learn. Distribute Reports. Produce Action Lists.  Another event happens. Repeat.

We have a growing list of failures to learn and little shift in learning. Vicious cycles indicate the need to shift paradigms, to think differently.

I propose we start by understanding the context and begin thinking integrally about how we learn.

Understanding the Context - Why don’t we learn?

An EVP of an O&G major told me how after a multi-fatality accident, they had rushed to get lessons out before the lawyers got involved.  I am often told about investigators being asked to soften their views when writing reports. 

We live in a world fixated on blame with little regard for inquiry and learning.  Faced with a serious accident, organisations must be responsible for legal, financial and reputational impacts. This does not mean they don’t care… it’s a function of the societal context we operate in.

A starting point in shifting paradigms is deepening our understanding of the societal and organisational contexts we operate in.  Awareness of this is in and of itself curative.

The following are some possible inquiries…

  • What is the current societal/organisational system designed to produce? (Look at what it does, it’s perfectly designed to do that)
  • How does this impact our ability to learn?
  • What societal/organisational barriers are there to learning?  Are these real or perceived?
  • What context or environment would we need to get better at learning?  Where could we start?  What could we do start doing or do differently?

Bringing an Integral Perspective

JMJ’s Integral approach ensures we move beyond relying on procedures and systems to drive change. Adopting an integral perspective enables sustainable change and breakthroughs in performance.

4 inquiries to begin creating an Integral approach to learning are:

1. How can we use more stories? (Personal)

Neuroscience is revealing how personal stories enable attitudinal shifts.  They engage different parts of the brain than conversations about facts and figures. Imagining and discussing the real or potential impact of events on workers and their families and communities will evoke a different type of conversation.

2. How can we bring a future focus to Lessons Learned? (Culture)

Learning from the past requires looking into the future. Many lessons learned conversations focus on understanding the past but fail to transfer those lessons.  Imagining where something similar could happen and discussing how to mitigate it enables learning.  Over time, it will build a culture of chronic unease.

3. How can we focus on principle-based rather than rules-based behaviours? (Behaviour)

A rule-based behaviour is ‘Don’t use your mobile while driving’. A principle-based behaviour is ‘Ensure you are not distracted whilst driving’.

Distinguishing the principle-based behaviours that accidents are pointing to, rather than relying only on rules will improve both the quality of investigations and lessons learned conversations.

4. How can we create a distinct and effective Lessons Learned process? (Systems)

All too often clients tell me that their process for learning lessons is emailing a summary of the investigation to a broad audience. Once the ‘send’ button is pressed there is an assumption that the lessons have been learned.

Developing a distinct system for learning lessons rather than tagging it onto the investigation process will reap benefits.  Make sure to include feedback and measuring success in the process.

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