Learning from incidents and accidents Eric Marsden <eric.marsden@risk-engineering.org> ‘‘ Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so. — Douglas Adams, author of Tie Hitchhiker’s Guide to the Galaxy
2 / 42 • railways: learning from operational experience analyzing incidents and learning from experience • military: lessons learned analysis • chemical industry: incident reporting, event analysis • nuclear industry: operational experience feedback Operational experience feedback ▷ Most companies with high-hazard activities have a formalized process for ▷ Terminology used depends on the industry sector: t e r m s e t h e w i l l u e s , w e s e s l i d I n t h e r a c k ” o f e e d b r i e n c e l e x p e a t i o n a “ o p e r O E F ▷ This activity is ofuen a requirement imposed by the regulator ▷ A complement to the accident investigation process
from past events in order better to control the future • collect information on anomalies, deviations, near misses, incidents and accidents • analyze the sequence of events and their causality • extract new knowledge or learning from the analysis • implement corrective actions or action plans • share the learning with all interested parties • record the learning so that it can help people in the future • identify improvements based on day-to-day operations • pdca / Kaizen / 6σ … 3 / 42 Operational experience feedback ▷ Operational experience feedback is a structured process aiming to learn ▷ It’s related to the idea of continual improvement
4 / 42 The experience feedback loop classify anomalies, analyze causes, de�ne corrective measures, plan their implementation manage implementation of corrective measures transfer information to the local manager communicate lessons learned to people potentially impacted change procedures, design, identify incidents, attitudes, safety behaviour, ... anomalies, accidents
anomalies and accidents • specify the severity of consequences afgecting people, the environment, production, process equipment • specify the severity level: for example catastrophic / high / medium / low • monthly reporting to the corporate level on number of incidents afgecting people, process, transport • immediately inform corporate level of events of high or catastrophic severity practices • safety discussion during team meetings • discussions at the water cooler 5 / 42 Implementation at the site level ▷ Reporting system (paper forms or computer tool) to declare incidents, ▷ For industrial sites that belong to a corporate entity: ▷ People on the site will also have informal experience sharing
Sample reporting form used by the Aviation Safety Reporting System run by nasa for the Source: asrs.arc.nasa.gov/docs/general.pdf ALL IDENTITIES CONTAINED IN THIS REPORT WILL BE REMOVED TO ASSURE COMPLETE REPORTER ANONYMITY. ACCIDENTS AND CRIMINAL ACTIVITIES ARE NOT INCLUDED IN THE ASRS PROGRAM AND SHOULD NOT BE SUBMITTED TO NASA. DO NOT REPORT AIRCRAFT ACCIDENTS AND CRIMINAL ACTIVITIES ON THIS FORM. 6 / 42 Page 1: information on the person reporting us faa , for incidents in civil aviation and technical details of the incident B ( SPACE BELOW RESERVED FOR ASRS DATE/TIME STAMP) IDENTIFICATION STRIP: Please fill in all blanks to ensure return of strip. NO RECORD WILL BE KEPT OF YOUR IDENTITY. This section will be returned to you. TELEPHONE NUMBERS where we may reach you for further details of this occurrence: HOME Area _______ No. ______________________ Hours __________________ WORK Area _______ No. ______________________ Hours __________________ TYPE OF EVENT/SITUATION NAME ____________________________________________________ ________________________________________ ADDRESS/PO BOX _________________________________________ ________________________________________ __________________________________________________________ DATE OF OCCURRENCE ___________________ (MM/DD/YYYY) CITY __________________________ STATE _____ ZIP ____________ LOCAL TIME (24 hr. clock) _________________ (HH:MM) PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION. REPORTER FLYING TIME (in hours) CERTIFICATES & RATINGS ATC EXPERIENCE O Captain O Single Pilot O Student o Flight Instructor O FPL O Developmental Total Time hrs O First Officer O Sport/Rec o Multiengine O Instructor radar yrs o pilot flying O Trainee Last 90 Days hrs O Private o Instrument non-radar yrs o pilot not flying O Dispatcher: yrs O Commercial o Flight Engineer supervisory yrs o relief pilot Time in Type hrs o check airman O Other: O ATP o Other: military yrs AIRSPACE CONDITIONS / WEATHER ELEMENTS LIGHT / VISIBILITY ATC / ADVISORY SVC. O dawn O night o Class A o Class E O VMC o fog o snow O Ramp O Center O daylight O dusk o hail o thunderstorm O Ground O FSS o Class B o Class G O IMC o haze/smoke o turbulence Ceiling feet O Tower O UNICOM o Class C o Special Use O Mixed o icing o windshear O TRACON O CTAF Visibility miles O Marginal o rain o other: ATC Facility o Class D o TFR RVR feet Name: AIRCRAFT 1 AIRCRAFT 2 Your Aircraft Type (Make/Model) Operating Other Operating (e.g. B737) NOT “N #”, Flt #, etc. : FAR Part: Aircraft: FAR Part: Operator o air carrier o fractional o military o air carrier o fractional o military o air taxi o FBO o personal o air taxi o FBO o personal o corporate o government o other: o corporate o government o other: Mission o passenger o cargo/freight o ferry o passenger o cargo/freight o ferry o personal o training o other: o personal o training o other: Flight Plan o VFR o SVFR o none o VFR o SVFR o none o IFR o DVFR o IFR o DVFR Flight Phase o taxi o climb o final approach o taxi o climb o final approach o parked o cruise o missed/GAR o parked o cruise o missed/GAR o takeoff o descent o landing o takeoff o descent o landing o initial climb o initial approach o other: o initial climb o initial approach o other: Route o airway (ID): o STAR (ID): o visual approach o airway (ID): o STAR (ID): o visual approach in Use o direct o oceanic o none o direct o oceanic o none o SID (ID): o vectors o other: o SID (ID): o vectors o other: If more than two aircraft were involved, please describe the additional aircraft in the "Describe Event/Situation" section. LOCATION CONFLICTS Altitude: (single value) O MSL O AGL Estimated miss distance in feet: horiz vert Was evasive action taken? O Yes O No Distance: and/or Radial (bearing): from: Was TCAS a factor? O TA O RA O No O Airport O ATC Fac O Intersection O NAVAID Did terrain warning system activate? O Yes O No GENERAL FOR M Page 1 of 3 NASA ARC 277B ( May 2009 )
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