13. Learning from Events

Learning from events is critical to drive continual improvement in safety, environmental and 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.