14 Dec How to expose, learn from and prevent persistent safety problems
I was engaged in a safety discussion on a pharmaceutical plant recently and it rapidly became obvious that the person I was talking to courted bad luck like Jonah. Although, as far as I could establish, she had never actually been swallowed by a whale (plenty of time for this though).
In her career she’d experienced an impressive variety of process disasters covering (large) glassware failures of various types, a water bath losing temperature control and boiling up, and a live steam line failure which activated the fire alarm.
I might add that she’d dealt with these challenges in expert fashion, if only by making it up as she went along because no one had seen these things before.
Plainly, the real solution to these problems is to put processes in place to prevent the incidents of course, but wouldn’t it be sensible to prepare people for these problems, just in case?
Further discussion revealed that details of these challenges and how to respond largely resided inside her head and weren’t really documented beyond the original incident investigation findings. Ideally this knowledge would be shared so that if said whale-swallowing scenario occurred the details would not be lost.
Many organisations have problems learning from experience
Who would have thought that a major modern financial failure first experienced in 1929 could be repeated in 2008 for us all to enjoy? If you are still in any doubt read ‘Lessons from disaster’ by Trevor Kletz: a magnum opus on the subject.
So your organisation needs to capture these failures and correct responses to them, ensuring that they’re referenced in operation instructions, a crisis manual or included in your training regime.
One of the advantages of engaging your staff in open conversation, free of recrimination, is that they frequently expose safety problems that people have faced and resolved themselves. Yet these learning experiences still need documenting formally and subsuming into the collective memory of your organisation, for want of a better description.