Abstract

In almost all organizations, incidents are analyzed and "lessons learned" are identified. Effective Learning From Incidents (LFI) fosters transformational learning and, as such, reduces the risk of incidents recurring that have the same/similar causes as an incident that has occurred (and been investigated) in the past. While many hard-won performance improvements have been delivered over the long term, achieving the next level of performance will require more than just incremental improvements. Although many organizations may struggle to effectively learn from incidents, relatively little is known about the specific bottlenecks in the LFI process. This paper builds upon the insights presented at the 2012 SPE conference in Perth (Drupsteen, Zwetsloot, and Groeneweg 2012) and provides insight into the most probable cause of lost learning potential: the implementation of interventions and evaluating their effect. A replication of the study in globally operating companies between 2012 and 2017 revealed no major shift. A disconnection between "those who investigate" and "those who implement actions" could be one of the causes of the lack of substantial improvement over the last decade. In this paper, a process-oriented approach is presented in which the bottlenecks in the learning from incidents process will be described and how in Shell Downstream Manufacturing the main issues were addressed by "creating more engagement in leaders" as one of the main objectives. This paper will provide practical insights into what it takes to improve the engagement of leaders for the learning process itself. It will present a number of "I Statements" to help leaders understand what they need to do as part of the change journey to take learning from incidents to the next level.

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