Simplicity in Safety Investigations

Chapter 1: Learning, mindset, and approach

• • What is learning?
• • Mindset
• • Approach
• • Chapter essentials

Chapter 2: Before you start

• • Key decisions: study level, scope, team formation, and roles
• • Learning Study level
• • Scope and team formation
• • A simple study
• • A detailed study
• • Roles
• • The art of facilitation and using a coaching style in facilitation
• • Your conversations and questions (before and after an event)
• • Chapter essentials

Chapter 3: Getting to ‘lessons to be learnt’ – the process

• • Step 0: Immediate response (Pre-Learning Study work)
• • Step 1: A decision to undertake a Learning Study is made
• • Step 2: Preliminary information gathering is completed
• • A side note on post-incident conversations/ interviewing (as compared to taking statements)
• • Generous listening
• • The interview conversation
• • Step 3: A Learning Study team is formed
• • Step 4: The team goes through the draft Work-As-Done timeline
• • Step 5: More comprehensive information gathering is undertaken by the team, including a PEEPO
• • How to run an effective and efficient PEEPO
• • Step 6: The timeline is completed, and ‘Elements of Interest’ are identified (determining Work-As-Done, Work- As-Normal, and Work-As-Written)
• • A side note on the differences between WAD, WAN, and WAW
• • Step 7: The contributors are listed for each Element of Interest
• • Hazards and risks
• • Understanding hazards, risk, and controlling of risk
• • Systems of work and their interrelationships
• • Shared space as it relates to safe workspaces
• • The limitations and use of situational awareness
• • Attitude and mindset
• • Understanding their ‘why’
• • The importance of attitude, internal decisions, and sense-making
• • The adoption of a growth mindset, including a learning mindset
• • Competency
• • Core ‘competency training’ and ‘awareness induction’
• • Experience
• • Process, tools, and equipment
• • Understanding of process and equipment
• • Equipment, tools, and plant design
• • Planning and task assignment
• • Task planning, assignment, acceptance, and monitoring, including communication
• • Understanding their own and others’ expectations
• • Answering a different question – that is, when the action doesn’t match the request
• • What-You-See-Is-All-There-Is and plan continuation
• • Efficiency-Thoroughness Trade-Off
• • Drift
• • Leadership
• • Accountability and authority mismatch
• • The level of understanding and curiosity about how work is actually done
• • Step 8: For each sentence, word, or statement created within the contributors, the team explores what we can learn
• • Step 9: Actions from Learning Study
• • Actions with SMARTS
• • Step 10: Write the report
• • Learning from Normal Work
• • Chapter essentials

Chapter 4: Converting lessons to be learnt into lessons learnt

• • Sharing versus learning
• • The process
• • How can we maximise the likelihood of learning remaining embedded in behaviour?
• • Chapter essentials

Chapter 5: Lessons we need to learn

• • Bhopal
• • Chernobyl
• • Space Shuttle Challenger
• • Herald of Free Enterprise
• • Piper Alpha oil rig
• • Space Shuttle Columbia
• • Deep Water Horizon
• • Fukushima Daiichi
• • Three Mile Island
• • Toulouse AZF Fertilizer Plant
• • West Fertilizer Company
• • Texas City Explosion
• • Flixborough
• • Longford Esso Plant
• • Gretley Mine
• • Costa Concordia
• • Flight AF 447
• • Sewol Ferry
• • Lac-Megantic Train Explosion
• • Phillips Explosion
• • DuPont Toxic Chemical Release
• • Grovepark Mills Explosion
• • Pike River underground mine explosion
• • LPG Fire at Valero – McKee Refinery
• • Catastrophic rupture of heat exchanger at the Tessoro petroleum refinery in Anacortes, Washington
• • AL Solutions metal dust explosion and fire, New Cumberland, USA
• • Nitrous oxide explosion
• • Ethylene release and fire
• • Imperial Sugar
• • Fatal Liquid Nitrogen Release. Foundation Food Group
• • The top 12 categories and their barriers
• • Learning from previous incidents (and audits)
• • Understanding of process, equipment, experience, and competence
• • Procedures and risk assessments
• • Critical processes
• • Emergency planning and processes
• • Management of Change
• • Leadership
• • Cost and production pressures
• • Shift handover and communications
• • Drift
• • Key performance indices
• • Maintenance and poor equipment
• • Overview
• • All 22 lessons to be learnt
• • Barriers
• • Chapter essentials

Chapter 6: Conclusion

• • Afterword, not after-thought
• • The quality checklist