tag:blogger.com,1999:blog-7585040184982733654.post2495609533174570056..comments2024-03-20T11:13:46.071+00:00Comments on Knoco stories: Closed lessons loops, examples from a lessons databaseNick Miltonhttp://www.blogger.com/profile/02413967879826601863noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-7585040184982733654.post-3156182194302420752014-01-24T11:39:44.144+00:002014-01-24T11:39:44.144+00:00Stephen, sorry for the delay. There are two good b...Stephen, sorry for the delay. There are two good books I would recommend for a discussion of high reliability organisations and safety - one is Flirting with Disaster - http://www.amazon.co.uk/Flirting-Disaster-Accidents-Rarely-Accidental/dp/1402761082 and the other is Managing the unexpected - http://www.amazon.co.uk/Managing-Unexpected-Resilient-Performance-Uncertainty/dp/0787996491.<br /><br />There is too much to summarise here, but some things to consider are <br /><br />a) Building a resilient system to start with (for example, the loss of the Herald of Free Enterprise may have been partly down to a system which relied on a crew member warning the captain if the bow doors were open, rather than confirming that they were shut. The crewman fell asleep, the captain heard no reason not to to set sail, and the ship sank)<br />b) Continual awareness and discussion of risks<br />c) Continual, reinforced, willingness to stop operations the moment things do not go to plan (for example the Aircraft carrier crewman working on the flight deck who found a spanner missing, from his toolbelt, and who closed down the entire operation until it was found. And was praised and rewarded for doing so).<br /><br />A high reliability organisation seeks to learn from every near miss or potential incident, and to avoid the creeping complacency that allows people to live with errors and make-do's.<br />Nick Miltonhttps://www.blogger.com/profile/02413967879826601863noreply@blogger.comtag:blogger.com,1999:blog-7585040184982733654.post-90195143339537105492013-07-18T00:31:35.762+01:002013-07-18T00:31:35.762+01:00Thanks Nick, look forward to an opportunity to cat...Thanks Nick, look forward to an opportunity to catch-up with you.<br /><br />Regards, StephenAnonymoushttps://www.blogger.com/profile/02745988545448735232noreply@blogger.comtag:blogger.com,1999:blog-7585040184982733654.post-59684567328052947022013-07-17T12:19:44.772+01:002013-07-17T12:19:44.772+01:00Hi Stephen
that's a big question, and I don&...Hi Stephen <br /><br />that's a big question, and I don't really have time to answer it just now I am afraid, as I am working overseas with a client and a deadline! Can I park the question until I can give it the thought it deserves?<br /><br />ThanksNick Miltonhttps://www.blogger.com/profile/02413967879826601863noreply@blogger.comtag:blogger.com,1999:blog-7585040184982733654.post-76080844659894298132013-07-17T11:59:13.994+01:002013-07-17T11:59:13.994+01:00Hi Nick, like the post. I agree with your views......Hi Nick, like the post. I agree with your views...My PhD lessons learned research has taken me down the safety lessons learned connection (safety culture, just culture etc). On another well known incident, I recall the review of the BP Deepwater Horizon accident investigation revealed how lessons learned of previous “well control event incidents” and “lines of communication” were not acknowledge or addressed and was a contributing cause to the failure (BP 2010, Deepwater Horizon Accident Investigation Repor: Cleveland, C 2011, Macondo: The Gulf Oil Disaster, Encyclopedia of Earth, http://www.eoearth.org/article/Macondo:_The_Gulf_Oil_Disaster?topic=64403). <br /><br />I understand that NASA uses the BP Deepwater Horizon incident as a lessons learned case study paying particular attention to communication deficiencies around government oversight, disregard of data, testing, changes to process, safety culture and lessons learned from previous incidents (NASA 2011, The Deepwater Horizon Accident: Lessons for NASA, Academy of Program/Project & Engineering Leadership, http://www.nasa.gov/pdf/592629main_BP_Case_Study_29AUG2011_FINAL.pdf).<br />I would appreciate your views on how high reliability organisations operate and their connection with organisational learning by addressing safety problems. They seem to have a flexible and informed reporting systems with a strong commitment to a safety just culture environment. How do we transfer this approach to safety into operational and project management lessons learned?<br /><br />Regards, Stephen <br />http://www.pmlessonslearned.info/<br />Anonymoushttps://www.blogger.com/profile/02745988545448735232noreply@blogger.com