Investigate & Learn

Expectations of leaders

1. Demonstrate care for the investigation team and all those impacted.
2. Ensure the investigation team is curios and wants to understand the causes of the incident.
3. Support your team in investigating incidents with high value learning, encourage them to actively participate in learning sessions and challenge them to adopt actions that will address the causes identified.
4. Support, challenge and encourage investigation teams to make the performance system of the organization visible by discovering technical, procedural and behavioral causes.
5. Create an environment in which gaining insight and preventing a repeat is the primary objective following an incident or near miss;
• Encourage staff to report incidents; remove blockers to reporting
• Openly recognize worksite staff who report events
• Avoid a rush to judgement
6. Allow your team to give priority to implementing corrective actions and verifying the effectiveness of actions.
7. Look back on previous notable incidents and verify that the actions are effective and sustainable.
8. Drive learnings and change based on record and external incidents;
• Establish clear roles and responsibilities
9. Ensure that for the incidents that are relevant to your assets, engagements take place with the relevant audiences and relevant action are established.

Reflect - Self

1. How do i engage my organization to value and prioritize high value learning?
2. How do i ensure that we incorporate causally-reasoned Human Performance analysis and Barrier Analysis in our investigations?
3. How do i know whether my organization has learnt effectively from its own incidents and from the incidents of others?
4. How do i drive effective and sustainable change in addressing causes and taking corrective actions that prevent repeat incidents?
5. How do i involve contractors to learn effectively from their and our incidents?

Ask - Others

1. What are the key themes of our HSSE data profile?
2. How do you ensure spend sufficient time to embed learnings (through engagements and corrective actions) from past incidents?
3. What are the latest learning this organisation has used to improve safety?
4. How was the learning from these incidents organised (internal, external)?
5. What are the latest learnings this organization has used to improve safety?
6. What changes were implemented?
7. How is it known whether learning from incidents, addressing cause and taking corrective actions is effective and happening is a sustainable way?
8. What are the strengths and areas for improvement of learning in this organization? How can it be improved?