Why aren’t organisations learning more from what goes wrong in their operation? We see deep-dive investigations turning over every rock until they produce a 10-page forensic study, hard-to-implement recommendations, and a few months later the same thing happens and off we go again with another ‘deep-dive’? Despite training in ICAM and other methodologies, we still have many clients dissatisfied with quality of learning and actions from serious incidents.

The result: frontline workers scratching their head; frontline leaders frustrated with the safety management system; real learning not happening; risk profile not changing.

Shifting your exposure to serious unwanted events is firstly an organisational learning challenge, and an objective longitudinal analysis of your incident history is the only way to avoid the cultural biases that constrain learning.

Recent work to solve this problem with our clients has enabled us to develop a thorough analysis process built around a unique causative model that uncovers:

• Breakdowns in critical controls that should have protected workers
• Causal analysis of those breakdowns: human, site and organisational
• Which change recommendations would seriously influence risk mitigation

While we’re here, if we’re talking about the “people” side of incidents, let’s call out just a few of the things that neuroscience points to why work goes wrong:

AUTO-PILOT

Repetitive or familiar tasks can lead to zoning out, and changes in exposure are less likely to be noticed. Consider how supervision is systemised to include mental nudges to keep people conscious of change.

COGNITIVE FATIGUE

Worse than physical fatigue as a driver of judgement errors and slow response to hazard. Can only be properly addressed with validated monitoring and a properly designed fatigue risk management system.

MEMORY FAILURE

Complex tasks can quickly outstrip a worker’s ability to hold task sequence in their head. Think about complex isolations and anything that requires more than 4-5 steps – they should be redesigned or have additional checks in place.

GROUP-THINK

We want our people to call out risk when they see it, but this can risk team relationships and experience hierarchy. Pre-empt this in pre-starts as a normal human response that must be actively fought against.

Of course, having the right answers is academic if executing necessary change doesn’t happen, but we believe high-quality learning is the FIRST priority.

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