Following a recent publication of the RAIB report of a fatal accident on WCML at Roade, Dr Shelley Stiles raises the importance of learning from such events and the challenge of building a learning culture and corporate memory.
As a health and safety professional, I feel it is important to review and digest learning identified from published reports into accidents and incidents, not only from the rail industry but from other industries. When the RAIB report into the fatality on the WCML at Roade was published earlier this week, I took some time to read the report and consider the key learning and how this can be taken forward with the organisation’s we support across the industry.
I then looked back to other published RAIB reports and recognised similar recommendations for the wider industry, also acknowledged by Simon French Chief Inspector of Rail Accidents who said.
This tragic and unnecessary loss of another life was the third fatal accident to track workers that RAIB has investigated in the last three years. This year, in February, there has been yet another, at Surbiton in Surrey.
This made me think – why are we not learning well enough to prevent the reoccurrence of harm? Why do we keep making the same mistakes?
From my experience the prevailing culture and health and safety climate of an organisation (and industry) can have a significant impact. Are investigations truly seen as an opportunity to improve? Or are they merely a process to follow, a box to tick on a database, a number in a spreadsheet? I see time and time again too much pressure on individuals and organisations to report events, investigate and close the actions out within unrealistic timescales. This drives a certain type of behaviour (and often bias) through the investigation with sometimes scant consideration of underlying and root causes that are really contributing and driving the unwanted outcomes.
Not forgetting of course, the pressure on the ‘recommendation management phase’ (or close out) which leads to action status being confirmed as ‘closed’, so the reports are moved from ‘red’ to ‘green’, and management can carry on with the day job! How often do organisations really test the effectiveness of those recommendations, several months or years down the line? This is something we regularly test with our clients to really understand how well the organisation learns from those adverse events. I believe that until recommendations are fully implemented, and improvements are made to become the ‘new business as usual’, then monitored and managed accordingly as part of an effective, robust and consistent risk management process, it should not be a surprise that similar accidents reoccur.
This goes back to culture and climate. For an organisation to develop a learning culture, learning needs to be embedded into how things are done at an individual, team and organisational levels. Leadership is key to create a learning culture through openness, support and challenge. Investing in the right resources is essential. If you are a leader of a business, take a few moments to think about the learning culture within your organisation, and what specifically you need to do to initiate/build/maintain learning from adverse events. Failing to learn is a tragedy, take the time to raise the bar.
A summary article is available here
A full copy of the RAIB report is here