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When a company experiences an incident, especially if the incident was severe or particularly damaging, it’s natural for leadership to want to provide a quick response to show the workforce they’re involved and doing something.
These responses will often include bulking up existing programs or policies by adding additional protocols or processes under the guise that more regulation will result in fewer repeat incidents. In fact, regardless of which industry you work in or what kind of work you do, there’s probably a good chance that many of the protocols or procedures you use every day came about as the result of an incident event of some sort.
The question that remains however is, are these administrative controls really enough to prevent incidents from recurring? For administrative controls like this to be effective at preventing incidents, they not only have to cover all the bases but they also have to account for the limits of human behavior and human nature—which we all know can be a large fly in the ointment.
One very famous example that does a good job of illustrating the true effectiveness of administrative controls at preventing future incidents would be the government’s response to the corporate financial scandals at Enron and WorldCom. In response to these massive cases of fraud, the government passed the Sarbanes-Oxley Act of 2002 which included strict accounting and reporting controls for publicly traded companies. These controls were designed to not only provide protection and security to the shareholders investing in and funding publicly traded companies, but it also made it harder for publicly traded companies to engage in fraud.
Now, while the Sarbanes-Oxley Act was instrumental at helping to prevent future cases of fraud within publicly traded companies, it wasn’t a complete solution because it didn’t include privately held companies. This left a large chunk of US companies vulnerable to people like Bernard Madoff who despite Sarbanes-Oxley, was still able to commit the largest financial fraud in U.S. history, bilking billions of dollars from unsuspecting investors.
This example really illustrates how even the best administrative controls can sometimes fall short of being a complete solution for preventing future incidents. So, what else could be included alongside administrative controls that would provide a more complete solution?
The answer is much simpler than you might think! Read on to learn about our new software module and how using lessons learned can work for you.
At some point in most people’s lives, they’ve either made this comment or heard someone else say it and it’s pretty much guaranteed that the context in which it was uttered was probably not as the result of something positive. But, whatever the lesson was, it was probably a valuable component in the quest to prevent that incident from happening again—because learning from our mistakes is how we get better. It’s how we evolve and improve.
Not convinced? Think about the last time you investigated an incident. During the investigation there were probably several “ah ha” moments that were uncovered or revealed throughout the investigative process. These were the moments that caused you to sit back in your chair and say “Lesson learned!” –and they are some of the most important moments that take place during an investigation. These moments are so important because they provide specific instructions for everyone who will perform the same task in the future—with examples!
For example, suppose a company has one permit required confined space that has to be entered for cleaning at least twice a year. Twice a year isn’t very often and with the complexity of the process and the potential incident severity of doing things incorrectly, the company really needs to make sure the participants know what they’re doing. Because the team managing this process is fairly new, they are unaware that the company has a history of serious incidents stemming from poorly managed confined space entries. Instead of doing a couple of dry runs or looking back at what happened during previous entries to make sure any mistakes aren’t repeated, they only provide a little bit of training before the actual entry begins.
This year the company also has a brand new employee who will be serving as the attendant to the entrants in the confined space. This person’s primary responsibilities are to stay in constant contact with the entrants and to get help if an entrant becomes incapacitated. Halfway through the entry, the attendant loses contact with the entrant and instead of going to get help, the attendant panics and enters the space to see what’s wrong. About 30 minutes later, both the entrant and the attendant are found unconscious inside the space.
The investigation that’s conducted after this incident reveals several lessons learned such as not skipping the lookback review of previous entries, only providing minimal training, forgoing the dry runs and practice entries, not considering a backup attendant and not considering the option of contracting out this work. In this case, what’s going to prevent future incidents from happening are the things gleaned from the lessons learned—not additional protocols tacked onto an already complex program.
At this point you might be thinking that trying to remember all of this, especially when this activity happens only twice per year is a tall order—but that’s where we can help.
In November, EHS Insight added a new module to our software family that’s specifically for managing and tracking lessons learned. In fact, the module is called the Lessons Learned Module. With this module, users can extract the lessons learned captured from an incident or quality event or during a safety drill—or they can create independent, standalone lessons learned that aren’t tied to an event.
From there the user is free to create a specific workflow that makes room for multiple levels of review and approval as well as allowing for the lessons learned to be rejected or canceled (with comments) during any part of the process, which sends it back down to the previous reviewer. Users are also able to include attachments and/or any document that has been uploaded into their Document Library.
Once the lessons learned have been reviewed and approved, the user can then generate what’s called a “lesson rundown”. The lesson rundown allows the user to create a checklist of all the lessons learned associated with a specific activity for the purpose of making sure nothing is missed the next time the task is performed and that incidents don’t get repeated. Within each rundown is the opportunity for the user to include rundown actions which are tasks to be completed. Rundown actions are assigned to either a specific person or a specific role and can be escalated as needed to ensure communication is maintained throughout the process.
When necessary, the user can also generate a series of reports, including a burndown chart which displays the planned actions within a lesson rundown and compares them to completed actions over time.
For people who may not think they have the type of operation that would benefit from this module, think again! As we said earlier, it doesn’t really matter what industry you work in because all industries experience incidents and can benefit from using lessons learned, especially when the lessons learned can be used to prevent additional incidents or to provide guided instructions for tasks.
Still not convinced? Here are a few examples of how more general companies could benefit from using this module:
Example 1: You own a landscaping company and the last time you had a big landscaping job to do, the amount of mulch wasn’t estimated properly. As a result, the employees managing the job ran out of their regular mulch and decided to go to the closest home improvement store to buy more only to find out it was out of stock. The employees decided to substitute the regular mulch with another type without realizing that the substituted mulch not only attracts fire ants but can also be toxic to dogs. In this example the two primary lessons here would be to estimate supplies a bit better and to have a list of allowable & approved substitutions. As the landscaping company owner, you can set up a lesson rundown from the lessons learned and every time a big landscaping job is awarded, you can assign actions to your team to make sure they estimate the proper amount of materials to complete the job and that they understand the substitution process before they start work. You could even attach a list of the approved substitutions that could be printed and kept on hand during the job.
Example 2: You own a company that provides security consulting throughout the United States. Right now you’ve got about 50 employees who work remotely and who travel throughout the country on a regular basis. Earlier this year the pandemic happened which affected travel and how your employees were able to do their jobs. One thing that you didn’t consider when employees were able to resume traveling again, were the wide differences in how each state was handling the pandemic. As a result, you had employees returning from travel who were required to participate in an unplanned 14 day post travel quarantine, while others traveled to cities where restaurants were not open and hotels were at capacity leaving a lack of accommodations and still others who traveled to states with mask mandates but were unable to wear a mask because of personal health conditions.
Using this module, you could create lessons learned from all of these experiences and then create specific lesson rundowns for each state that your employees travel to. Each lesson rundown could be assigned based on where an employee travels and could include any pertinent documents with health guidelines or travel notices—and could even include creative rundown actions such as taking a picture of a compliant face mask and uploading it for review and approval prior to travel.
No matter how you look at it, lessons learned play a key role in the prevention of future incidents. If you’re serious about incident prevention, contact us and let us help you take the next step towards an improved safety program!
Katy Lyden is a EHS Domain Analyst and Subject Matter Expert for StarTex Software, the company behind EHS Insight. Prior to her current role, Katy spent 17 years successfully leading EHS programs for several large companies within the manufacturing industry. Katy is a Navy veteran, Licensed Emergency Medical...
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