Learning from incidents

Analyzing incidents using a barrier based philosophy is a common occurrence. Learning from individual incidents is becoming more ubiquitous, we know roughly how to do it. The challenge is to learn from many incidents.

In the area of risk assessment, the same barrier philosophy can be applied. The bowtie method is the most advanced barrier-based methodology for risk assessment.

Both of these methods, incident analysis, and risk assessments are used in their respective areas; one is reactive, the other is proactive. Both follow the same barrier-based philosophy, which makes the two compatible to exchange information. Merging the information from these two approaches can have tremendous benefits. Using the findings from incidents to update a risk assessment can help in aggregating and seeing patterns emerge across incidents.

Some of the advantages are; combining several near misses to see the potential for looming future incidents; extrapolating the failed controls from one scenario to another; uncovering and updating the risk assessments with information from incidents; using the risk assessments as a final quality check on the incident analysis.

 

Process Deviation Management

Analyzing and understanding incidents is nothing different than analyzing and understanding process disruptions from an operation point of view. The same methods, the same tools, and the same applications can be used for this purpose.

Process Deviation Management is about capturing, analyzing and managing data and improvement actions related to process deviations “from a barrier perspective|. Process deviations can be about operations, HSE, and quality.

The essence is to understand which controls or barriers have failed or proven to be reliable – and why (5x) this is the case. Furthermore, the barriers are linked to your management systems, so you know who is responsible, which procedures are applicable and what the (status of the) improvement actions are.