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13. Learning From Events

Learning from events is critical to drive continual improvement in business performance. An effective Learning From Events system transforms undesired events into improvement opportunities. Managers should strive to create a "no blame" culture in the organisation to foster high levels of event reporting. Personnel should be particularly encouraged to report near-misses which offer the greatest number of learning opportunities. All events should be risk assessed and investigated appropriately, involving both managers and front line personnel. Investigations must uncover the basic causes of events before determining the necessary corrective and preventive actions. Actions must be tracked to completion and the results communicated to all necessary stakeholders. Insights from events should be periodically reviewed to look for patterns and trends that may need to be addressed.

The sub-processes are listed below:
 
13.1. Learning from Events System
13.2. Learning from Success
13.3. Participation in Investigations
13.4. Near-Miss and Sub-standard Conditions
13.5. Complaints Management
13.6. Event Announcements
13.7. Away-From-Work Accidents
13.8. Action Follow-Up
13.9. LFE Reporting Verification
13.10. Event Analysis
13.11. Problem Solving Teams

 

Learning from Events explained by Nicholas Hiew from DNV GL Singapore