From Black Books to Learning

The challenge of learning from incidents. From awareness to identify, transfer, and sustain

In this final article in the series, we examine the subject of learning from incidents and the challenge we face in identifying, applying and sustaining learning within our organisations.

THE day I started work at a well-known international chemical company in the 1980s I was issued with an induction checklist: a set of assignments that included a list of people I had to meet, subjects I had to discuss with them and documents that I had to read in my first three months in the organisation. I had to complete the assignments and have them signed off and placed in my training record.

Looking back on it more than 30 years later it seems a very enlightened approach, but for an engineer with several years of industrial experience eager to get out on the plant, learn the process and make a quick impact, it felt like a bit of a distraction.  One item on the list of documents I had to read was entitled simply, “The Black Book”. It turned out to be a collection of lever arch files containing a compilation of investigation reports from the site’s most serious process safety incidents dating back to the origin of the site in the 1930s; fatalities resulting from toxic releases, asset damage from fires and explosions, and pollution events involving the local river (some of which would be national news events these days).

The Black Book was – and doubtless still is – a fascinating and chilling insight into the history of that site and the hazards of the process, made very real by the black-and-white photographs of the scenes and the names of those who had lost their lives. However, it was only years later – in the role of the company’s Safety, Health and Environmental Manager – that I came to really value the Black Book as an effort to sustain the company’s corporate memory. I put time into making sure it was as complete as possible, preserved electronically and shared across the company world-wide, enabled by the onset of the internet era. I also took some time out with colleagues to review the events and look for similarities between events across the 60 years of the site’s history. The results of that work indicated that quite similar events seemed to repeat themselves every 10–15 years or so, something that we loosely correlated with the turnover in “generations” of production staff. This raised the question that the process industries still face…how to apply and sustain learning from past incidents, both within and from outside of the organisation. As the late Trevor Kletz is often quoted as saying: “Organisations have no memory; only people have memories and they move on”.¹

Organisations have no memory; only people have memories and they move on

With hindsight, I believe that the Black Book concept – in common with other ways of sharing incident investigation reports – is a valuable way to raise awareness, but awareness doesn’t necessarily equate to learning. Awareness is a state of mind, a consciousness which is often only temporary. To learn from incidents we need more than this; we want to transfer or apply learning to new situations in order to prevent potential future incidents. In the field of problem-centred learning, “transfer of learning takes place when knowledge, abilities and skills assist us in the performance of new tasks or affect the next step in the learning process.”². It is the process of transfer that we need to focus on.

Golden rules

As an example from the site at which the Black Book was developed, over many years a set of simple rules was developed relating to the handling of the site’s principal highly toxic material: “Keep it pure; keep it dry; keep it acidic; keep it cool; keep it moving”. This set of “golden rules” was relatively easy to learn (I still remember it more than 30 years later) and straightforward to apply or transfer in design or operational decision-making. Indeed, these “golden rules” have been spread across the world at industry sector group conferences.

Coming back to learning from specific incidents, in the process industries we frequently bemoan our collective failure to learn from the past. The challenges are numerous:

• identifying and facing up to the systemic causes of our own incidents;
• applying lessons from very complex external incidents (as many process incidents are);
• fighting cognitive dissonance (“it couldn’t happen here”);
• the sheer volume of information from our own “near hit” and external incidents; and
• sustaining learning through organisational changes.

Addressing these challenges is far from straightforward, but the table below provides a relatively simple framework to assist in learning from incidents both inside and from outside the organisation, helping to focus on the process of identify > transfer > sustain.

The flip side of this last question is the old management of change saying: “Don’t change or remove anything unless you know why it is like that now”, which is why it is useful to state in design guides, procedures and basis of safety documents why things are specified as they are (and why not mention the incident from which the learning came?).

To conclude by going back to the Black Book concept, why not commemorate the key incidents from your site’s or industry’s past on their anniversaries, challenge the way in which the lessons are being applied and ask yourselves how learning will be sustained in future as people leave your organisation and move on, taking their memories with them.

References

1. Lessons From Disaster – How Organisations Have No Memory And Accidents Recur, Kletz, IChemE, 1993, ISBN 0-85295-307-0.

2. Mila and Sanmarti, 1999 quoted in Problem-based Learning: Welcome to the Real World, Wendy J Flint, Word Unlimited, 2007, ISBN 1-4196-7403-X.

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This is the final article in a series of seven. You can find the whole series at https://bit.ly/2GW1F72.