12. Sharing lessons learnt from accidents
This chapter provides principles to support the sharing of lessons learnt from accidents. Industry, public authorities and other stakeholders should improve efforts to promote sharing of lessons learnt from accident reports and investigations, and to facilitate communication of these lessons learnt as quickly as possible.
Sharing the lessons learnt from incidents is the responsibility of all stakeholders. This includes academia involved in the training of students and research, industry associations, non-governmental organisations (NGOs), the insurance industry including brokers, intergovernmental organisations (IGOs) as well as industry and public authorities.
Lessons from accidents need to be identified and disseminated and the appropriate actions implemented. This needs to become a process of continuous improvement for all involved (Box 12.1).
Efforts should be made to promote sharing of lessons learnt and facilitate communication as quickly as possible.
It is important to avoid repeating accidents by paying particular attention to lessons that have already been identified from accidents or incidents that occurred, either inside the enterprise or elsewhere.
It should be recognised that it may not be enough to simply publicise “lessons learnt”; efforts should be made to understand how to communicate the information in a way that will result in appropriate actions being taken. In this regard, lessons learnt can form an extremely important part of education and training programmes.
Efforts should be made to identify barriers to sharing information about investigations and lessons learnt including possible concerns about legal issues and protection of confidential business information, and finding ways to minimise these.
Industry, public authorities and other stakeholders should improve efforts to promote sharing of lessons learnt from accident reports and investigations and to facilitate communication of these lessons learnt as quickly as possible.
Lessons from accidents need to be identified, disseminated and the appropriate actions implemented.
Management of hazardous installations, as well as industry associations, public authorities and other stakeholders, should consider how to create a climate that fosters trust and encourages voluntary sharing of information concerning accidents and near misses, including lessons learnt.
Leadership, from the highest levels in enterprises and public authorities, is essential to ensure that lessons are learnt from incidents and that appropriate actions are taken as a result.
Public authorities should facilitate the sharing of accident reports within industry and, as appropriate, with other interested parties.
There is a need to better understand how to communicate lessons learnt in a way that will result in appropriate actions being taken to reduce the likelihood of similar accidents occurring in the future.
Efforts should be made to identify barriers to sharing information about lessons learnt and to find ways to minimise these.
Efforts should be made to develop a basic agreed framework and use common terminology for preparing investigation reports in order to facilitate sharing of information related to investigations.