How Better learning From Accidents & Near Misses Can Transform Safety Culture Part 2

Hello, my name is Ian Pemberton. I'm managing director of Human Focus. I'm a chartered ergonomist or human factors specialist.

I've got a free CPD live webinar coming up on the 23rd of March 2 p.m. GMT,?titled How Better Learning from Accidents and Near Misses Can Transform Safety Culture Part 2.

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Now, this is Part 2, because as it suggests, it's a multi series set of webinars.?Part 1 was on the 16th of February and I put together a series of short videos to preview, what we're going to be covering in Part 2. And, as part of this, I will be answering some questions that were raised in Part 1 of this webinar as well as looking ahead to see what we're going to do in Part 2.

So in Part 1, what I introduced was this organisational, learning framework, which is got three elements. The first is, if you are going to learn effectively, you have to be able to gather information from work as done. You actually have to know what's going on at the sharp end and what I showed with the were many obstacles, common obstacles from effectively gathering this information. Then, once you've got the information, in the second element of this framework, you've got to be able to draw meaningful lessons from that information and again, I looked at many elements of why organisations fail to draw effective lessons. And then in the third element of this framework, I introduced the concept that just learning some lessons doesn't magically implement improvements as a result of that. So very often, for example, after an accident investigation, there's a report written and there's an assumption that just because that goes on a SharePoint that there's going to be some magical change.

It doesn't work like that. So, you've got to have a way of implementing the information, getting out there and this is the third element of the framework. And actually this is a continuous improvement process. It's not a one-and-done exercise. So you got to have a way of continuously doing this and I introduced the concept that there's three main problems or hurdles to overcome. The first is in gathering the information, organisations tend to intimidate workers. And there's various reasons that they do this but fundamentally all ends in the same place. They intimidate the worker which means that people are fearful, or reluctant to actually raise their hand and say, ‘hey, there's a problem here’. And we looked at a number of reasons why this is so.

Then when we get over into drawing, meaningful conclusions, they tend to blame the worker. They don't necessarily do this deliberately or even knowingly, but the end conclusion is that you get superficial lessons learnt, are very superficial because it’s?‘somebody messed up there’.?Why did they do that? Human error, give them some more training and that kind of conclusion. So always are often ends up in blaming the worker.

And then, finally down in the third component of implementing improvements. What we looked at there is, there's a natural tendency to basically ignore the worker. And by that I mean that there could be some good lessons, some good insights, but there's a failure to follow through and we looked at the science there of how multiple research studies have found that this is a very common missing link, of how to actually get the information out to your workforce.

And one common one there was, it's often done in a, in a broadcast way. ‘Hey, look, we've had an accident, do this, do this’. And the assumption is just because you push it out as a broadcast, people are going to listen. And they often don't.

Real learning is about getting engagement of your workforce in this information, getting a two-way process going where they're feeding back information to you, as well as you pushing information out.

So, there you go. We looked at how we intimidate the worker, how we blame the worker, and how we ignore the worker. That's what we looked at in Part 1. I extended this framework to look at, there are often 15 common hurdles.

So there you go in. There's 1 to 4 in gathering the information. And there's 5 to 11 in drawing meaningful lessons. And then there were 12 through 15 in implementing improvements. So the reason why this is a multi-part webinar and Part 2 and so on, is that we?didn't have enough time to go into all the detail of these common hurdles. And so in Part 1, we looked at hurdle number three, there poor psychological safety.?I looked at what is psychological safety, and how this really underpins effective reporting by workforce of incidents so that you can gather the information.

And I went over into drawing meaningful lessons and looked briefly there at Complexity Theory. Number six there. And how a really deep understanding of Complexity Theory is really important to effective drawing of lessons.?And then finally down at the bottom there. I looked at number 15. Inaccessible information. Information that's basically word-based, reports that don't really give the information visually in an accessible way. And how, that's often a barrier to getting the information out.

So that was Part 1.?In Part 2 of this webinar. I'm going to be diving into greater detail into some of these 15 common roadblocks that I've come across in 30, odd years of professional practice in this in this sector. So if you attended Part 1, and you're interested to learn more, go ahead and register.?If you haven't, if this is new to you, and you want to get better learning from accidents and near misses and how this can help to transform your safety culture and?reverses is also true, how changes in your safety culture, can help you with better learning, if you want to explore this learning framework and you want to, you want more valuable information about these 15 roadblocks, then go ahead and register 23rd March, 2 p.m. It's a completely free webinar. Go ahead and register.

And look out for the next video in this short briefing series, where I'll be explaining a little bit more about what's coming. And some of the things we looked at in Part 1. Thank you for watching. I hope you found this useful.

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