Company Memory-Lessons Learned

Company, every member of investigation team learns about problems that precipitate accidents. This new knowledge helps every team member avoid similar situations in the future. In the investigation is appropriately reported, many others will also benefit.
This concept is also important for reporting minor accidents or near misses. Minor accidents and near misses are excellent opportunities to obtain “free chances” to prevent larger accidents from occurring in the future. It is much easier to correct minor problems before serious accidents occur than to correct them after they are manifested in major losses.
Accident investigations are designed to enhance learning. The fundamental steps in an investigation include –
    1. Developing a detailed description of the accident
    2. Accumulating relevant facts
    3. Analyzing the facts and developing potential causes of the accident
    4. Studying the system and operating methods relevant to the potential causes of the accident
    5. Developing the most likely causes
    6. Developing recommendations to eliminate recurrence of this type of accident
    7. Using an investigation style that is fact finding and not faultfinding; fault finding creates an environment that is not conducive to learning
    Good investigations help organizations use every accident as an opportunity to learn how to prevent future accidents. Investigation results are used to change hazardous practices and procedures and to develop management systems to use this new knowledge on a long-term and continuous basis.
    Reference: CCPS(1989) Guidelines for Technical Management of Chemical Process Safety
    Management/Incident Investigation