In a perfect world, personnel would be able to learn from their mistakes without ever running the risk of getting hurt.
However, until we’ve developed the occupational-safety equivalent of respawning in a video game, we’ll have to settle for learning from our mistakes. Best practice dictates that modern organisations need to be learning organisations that constantly reflect on their performance and learn from mistakes.
Learning from incidents at an organisation provides benefits not just for the site affected, but for the business as a whole. Furthermore, these lessons are often valuable to the entire industry to promote a culture of safety awareness that transcends the concept of ‘pockets of excellence’. How should we leverage our learnings from past incidents to ensure that what remains serves a reminder to the business and the industry as a whole?
Prominent sociologist, Diane Vaughan, coined the concept of ‘normalisation of deviance’ to describe how businesses drift from the lessons learnt from incidents over time.
Typically, there is a flurry of activity directly after an incident.
This inevitably influences changes to procedures that are subject to ongoing improvement. Unfortunately, despite the best intentions of the team responsible for the investigation and recommendations, learnings are steadily forgotten or reinterpreted over time.
Here are a few things to consider next time you are tasked with communicating learnings to your business to avoid normalising deviance.
RE-CREATE THE INCIDENT
Incident re-creations show a workforce what happened in the moments leading up to an event. These can range from a basic presentation consisting of photos of the incident scene, to video footage re-enacted by personnel to sophisticated 3D video. The latter allows the business to view the incident from a number of angles without the potential of further injury. Be tactful when presenting this type of content as recent events are often still fresh in the minds of those involved, and can be traumatic.
INTERVIEW THOSE INVOLVED
A quick way to share the human element of an incident is to conduct an interview with those involved, particularly if the incident is considered a near-miss. People find it easy to relate to the experiences of their direct peers. Where possible, record the interview using a mobile phone or digital camera, and share it via the company intranet. Just remember to stabilise the phone or camera in some way, and once again be tactful with those involved.
CREATE A SCENARIO
Scenario-based learning is considered leading practice in training circles for good reason. Firstly, they allow people to explore the outcomes of their decisions in a safe environment. Secondly, they are an opportunity to practice the skills they have acquired. Developing an eLearning module allows personnel to continually explore and reflect on the decisions that lead up to the incident.
WORK ON YOUR INCIDENT INVESTIGATION PROCEDURE
A well-developed incident investigation procedure is the first step towards learning lessons of real value from incidents. By fostering a culture of comprehensive and accurate investigation at your business, you will be encouraging personnel to regard learning from the past as part of the way you do things. Additionally, methodologies like ICAM provide a structured way to arrive at the real cause of any incident and formulate recommendations for the business.
By reconsidering the method by which we respond to past failures and by creating training that can be used to stop complacency from setting in, we minimise the risk of normalised deviations and their potential to lead to future injuries.
Kevin Brew
Instructional Designer
Add Comment