A common challenge in safety is ensuring that lessons learned from incidents are incorporated in such a way as to eliminate or substantially reduce the potential for recurrence. For years, we have applied recognized causal analysis tools and corrective action philosophy. In the spirit of continuous improvement, the entire incident investigation process was reviewed to look for better methods.

Through our review, we discovered that although we conducted investigations they did not always determine root causes. When they did determine a root cause, we struggled with implementing effective corrective actions and applying lessons learned across multiple sites. Consequently, in many instances, the corrective actions did not always prevent repeat incidents. In addition, findings or corrections were not consistently shared throughout similar operations, which provided the possibility of similar occurrences at other sites.

Through research, collaboration, education, and communication, we have developed an effective model for reducing repeat incidents. This model can be used to solve problems, proactively or reactively, by using a combination of elements from commonly used causal analysis tools, as well as corrective action mechanisms. After an investigation, a high-level peer review is conducted to understand the findings and fidelity of preventative measures. To ensure follow-up, the findings and corrective actions are loaded into tracking software. Each action has automated notifications and escalation triggers if it is not completed timely. Reports are published to the intranet on a daily basis to show the progress of each item. The final and concurrent step is to share with other sites by uploading the entire investigation into a portal. The portal has notification capabilities and several hundred subscribers receive an email notification when a new document is posted; subscribers are expected to review and assess the applicability of the new information.

Improved quality of investigations, a drive toward sustainable corrective actions, and sharing implementation across the organization has contributed to an overall reduction in incidents and to an increased awareness and recognition of hazards. This method increases organizational visibility and accountability. It also creates an environment that promotes learning from incidents and taking actions that will reduce risks.

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