Learning from what happens.
WHAT TO REPORT
Injuries Near misses Dangerous occurrences Damage incidents Unsafe conditions
WHY NEAR MISSES MATTER MOST
They reveal the failure without the injury, and they are far more numerous.
WHAT MAKES REPORTING FAIL
Blame Complicated processes No response to reports
WHY NO RESPONSE MATTERS
People stop reporting when nothing happens.
WHAT TO ESTABLISH
A simple route, and a response to every report.
WHAT TO DO IMMEDIATELY AFTER AN INCIDENT
Attend to the injured person Make the area safe Preserve the scene where practical Notify whoever must be told
WHAT TO PRESERVE
Equipment involved Conditions Records
WHY
They are the evidence, and they change quickly.
WHAT TO RECORD
What happened, factually When and where Who was involved What they were doing Conditions What action was taken
WHAT TO AVOID IN THE RECORD
Speculation Blame Conclusions
WHAT INVESTIGATION SHOULD ESTABLISH
What allowed it to happen.
WHAT TO ASK
Why, repeatedly, until you reach something that can be changed.
WHAT NOT TO STOP AT
Human error.
WHY
It is never the end of the chain.
WHAT TO PRODUCE
Actions: specific, owned and dated.
WHAT TO VERIFY
That they were completed and that they worked.
WHAT TO ANALYSE
Incidents over time, by type and cause.
