Accidents and Incidents - backward control of unwanted events

Accidents, incidents and other type of unwanted events and their losses are an excellent source to improve the management system and further control loss. The reasoning behind this is that – in principle – all unwanted events can be prevented and they all originate from the management system. 

Unwanted events such as accidents, errors, mistakes, omissions, oversights, etc. - are good sources to learn from and to take steps to make sure that the same or similar will not happen again. 

Learning from accidents and incidents and other unwanted events

Learning from unwanted events requires:

• Know what happened - register facts for communication and cause analysis
• Know why it happened - carry out cause analysis
• Know why the consequences were what they were - evaluate post event actions
• Carry out remedial actions - make sure they will be done well and on time; assign responsibilities
• Let others know - communicate and report so they will learn as well

You need to have a system similar to what is described in an accident investigation protocol. The protocol describes the process to learn from unwanted events such as accidents, incidents, complaints, etcetera. 

Learning from No-Loss events

Learning from accidents with relatively minor consequences, or no consequences at all, is a better way to learn ... but you need to have a risk classification system to make them important. So that resources will be made available to investigate, analyze and take remedial actions.  

Risk classification could also be used when evaluating deviations noted during inspections or behavior observations. If fact, the substandard acts or conditions observed could result in loss .... if the circumstances would have been different.

From accidents to the management system

While learning from accidents covers all aspects of the accident causation model, the real learning that will prevent similar events to happen again - possibly with a much greater impact - accumulates in the area of the management system , its work processes and related procedures, work methods, etc.

It is in the management system that the experience from unwanted events comes together to further improve the system - the organization's "memory" and the "way we work" - to prevent unwanted events and their consequences in the future: Learning From Accidents. 

Learning from unwanted events accumulates in the management system giving direction to procedures and instructions and determining how work places and installations are to be designed and equipment is to be purchased. How work procedures are to be set up and people are to be trained to properly, safely, carry out their work. This way the management system, by creating a better working environment and better communication, helps to mold the culture of the organization while at the same time obtaining better cost control and sustainable profitability.

Should you investigate all minor or no-loss events?

I do not think so. You want as many as possible reported and you want to record them for trend evaluation and you want to know what these small losses cost you per period. 

After they have been reported, recalled or imagined, use a risk classification tool to find the high potential (HIPO) events that could lead to serious loss and carry out a cause analyses on those.

Be aware: giving too much attention to events that will not and cannot generate important losses may lead to demotivation of people, including management.