Plant Safety: Effectively Share Insights from Incidents

A proven approach can ensure lessons get communicated and acted upon

By Mike Bearrow, Rolls-Royce Controls and Data Services, and Kim Turner, consultant

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We all are continually learning. Learning from our own mistakes as well as from the experiences of others makes us better prepared to deal with future events. Organizations are no different — successful ones use insights gained from mistakes, incidents, accidents and other undesirable occurrences to improve.

Identifying those lessons you really must learn, regardless of their source, and putting into action a process to take advantage of the learning is the very definition of continuous improvement that can make your organization safer, smarter and more sustainable. The opportunities those lessons afford can play a key role in remaining competitive, effective, efficient and profitable.

Every site in your organization spots local opportunities. However, some ideas, e.g., ones related to operational improvement or process safety, that could have broader applicability often don’t get entered into a corporate knowledge- or incident-management system because site staff don’t appreciate their wider value to the organization.

Only a small percentage of opportunities identified at a facility will be important to its larger business unit. Even fewer will have enterprise-wide relevance (Figure 1). However, those that do must be managed in an efficient and effective way.

Six Steps To Safer Processing

An organization should look for more than internal ideas. It should check for opportunities uncovered elsewhere. Regulatory bodies often spell out general lessons from major events. So, review high-profile incident investigations and findings — e.g., on the explosion at BP’s Texas City refinery, the Buncefield fuel-depot disaster in the U.K., and the Fukushima nuclear catastrophe in Japan — for opportunities that might apply to your organization. Changes in reporting requirements by the U.S. Environmental Protection Agency and Occupational Safety and Health Administration, and the U.K. Health and Safety Executive’s Control of Major Accident Hazards (COMAH) regulations also mandate all facilities to react and adapt.

In addition, you must consider how your organization manages global opportunities today. Often, it involves casual or informal sharing. Unfortunately, this usually is inadequate because the appropriate people in your organization may not see or understand the opportunities. Companies are using different techniques today to address this tough problem — with mixed results. We recommend an approach called HUAA that has proven effective.

A More Effective Approach

HUAA stands for Heard, Understood, Acknowledged and Actioned. It consists of the following core steps:

1. Identifying opportunities (Heard);
2. Entering them into an electronic system;
3. Having experts review them (Understood),
4. Accepting or rejecting them (Acknowledged); and
5. Assigning each to leadership to resolve and track to closure (Actioned).

A good HUAA process provides visibility to leadership about the opportunities being identified, and reports on the progress in real time (Figure 2).

The approach offers a number of other significant benefits:

• Efficient collection. Important opportunities from many sources (internal and external) are collected and entered into the HUAA management system, streamlining the recording process and getting the opportunities quickly to decision-makers.
• Expert review. These opportunities are vetted, parsed and resolved for inclusion or exclusion, with the decision documented and communicated.
• Accountable assignment. Accepted opportunities are systematically assigned to leaders and managed across the enterprise at the executive level.
• Action. Leaders are held accountable for their actions. Moreover, results of their actions as well as inaction can be seen real time, which spurs action.
• Results. The organization will gain competitive advantage by active listening, learning from its experience as well as the experience of others, and by taking action. The results of the process can be audited, judged and continually improved.

The HUAA process can underpin an organization’s knowledge-management strategy and provide the most important part — action!

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  • • Isolated Cases An inescapable fact is that few, if any, harmful conditions, behaviors, actions, or inactions are one-of-a-kind, one-off, isolated, unique examples/cases. There is a consistency of performance/process/leadership/culture that tends to replicate results/ outcomes and create extent . When a harmful condition, behavior, action, or inaction appears to be a one-of-a-kind, one-off, isolated, unique example/ case it is almost always a symptom of dysfunctional observation. The item does have extent, but the extent is not seen. “Cockroaches never travel alone. If you see one on the kitchen floor, expect thirty under the fridge.”


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