Should Lessons Learned be the Blueprint for the Future

摘要

Do we need a journey through the past to make our future betterMany companies say they have a Lessons Learned process as part of their management system.Whilst the intent is sincere,a review of major accident events suggests this is not working.Why is there no sense of anxiety around this failure to learn and prevent reoccurrenceFrom a review of various major incidents around the world,we conclude that all possible lessons have not been learned from preceding events. In one sense,a failure to learn is understandable.Since catastrophic accidents are not common,it is easy for people to believe that similar incidents won’t happen to them.Their rarity also means that the generation who were in proximity to a major incident and were deeply affected by it,will in time move on.Trevor Kletz recognised this issue many years ago in his 1993 book,“Lessons from Disaster”or“How organisations have no memory and accidents recur.”(Kletz 1993) However,is this too pessimistic a viewWhat can we do about building more risk aware organisations and minimising reliance on active risk mitigation systemsMuch work has been done already,mainly in the field of identifying lessons to be learnt.This is not the same as actually learning the lessons,which is more difficult.We discuss the mechanisms at work which causes lessons not to be learned along with the various psychological characteristics and traits at play that can affect our ability to learn. This paper discusses the following essential features of an effective lessons learnt process: A requirement to look outside the organisation and industry for sharing of lessons to learned; A process which goes beyond identifying the lessons to be learnt but has a method to embed or internalise the lessons and actually minimise the risk or eliminate the defect; A specific organisational capability in making changes with senior management patronage; Measurement to check the organisation is applying the lessons and behaviours and hardware have changed in practice. We will argue that some lessons are learnt.These are notably to do with personal safety,the normal industrial risks we face at work.However,it is not clear that this is the case with process safety(or major accident events,MAEs which is the term we will use here).We will give some examples of incidents which have recurred and some cases keep recurring.It will offer some explanations of why this is the case including some of the human factors(psychological and organisational)reasons. We will then give some examples from the history of the oil and gas industry of where we have failed to learn and finally offer some possible solutions for improving our lessons learnt capability including potential legislative change.