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Lessons Learned
The real reason for accident investigations.
www.keepitsimplesafety.com
Why Lessons
Learned?
• You’re doing incident reviews, that’s great, and we bet they are great, but what are you doing with them?
• Incident Reviews are meant to discover failures in the system or process that led to an unplanned event, along with corrective actions.
• Many times, in the best of management systems, managers and supervision collaborate heavily to determine findings and actions, and then this message makes its way out to the work force through supervision and training. Sometimes it takes a while.
www.keepitsimplesafety.com
How can you make the process more efficient?
We believe an incident review with the intent to share becomes a Lesson Learned process. It is the most efficient way to both share expectations and demonstrate the failure against those expectations with images.
www.keepitsimplesafety.com
Lessons Learned
• A summary of an accident investigation which simplifies:
• What work was being done. (What were they doing?)
• What caused the incident. (What went wrong?)
• What can be done to prevent re-occurrence. (How can we keep it from happening again?)
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Guidelines for Lessons Learned• Should be limited to one page, two at
most.
• Use insert>shapes in power point to give your re-enactment photos better context.
• Limit issues and ideas to three each, keep it simple.
• Verify basics of lessons learned with impacted crew prior to distribution.
• Convert to adobe to prevent editing.
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Lesson Learned [DATE]
[Scope of Work]
• What happened?
• Describe crew activity leading up to incident…..
• What went wrong?
• Causal Factor #1
• Causal Factor #2
• Causal Factor #3
• What can we do to prevent this?
• Preventative Idea, Crew Focused
• Preventative Idea, Crew Focused
• Preventative Idea, Crew Focused
Re-enactment photo(s)www.keepitsimplesafety.com
Example 1Turbo Torch Fire
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Lessons Learned February 3, 2007Turbo Torch Fire
What went wrong?The hose/torch connection was leaking.
What did they do?
1. The job purchased new turbo torches to ensure that all equipment was in good shape.
2. The job held a tailgate meeting to discuss methods of detecting leaks in turbo torches.
What do we do to keep this from happening again?1. Inspect all hoses and connections for leaks prior to use.
2. Beware of cross threading, dirt in the threads of connections, and damage to your torches and or hoses that may cause a leak.
It Happened To Us!!Last year, a leak accumulated in an employee's glove and once ignited caused 2nd degree burns to the hands.
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"Tips From The Pros"
Pull back the rubber sleeve that covers the hose-torch connection to ensure that no leaks are present. It is advised to do this daily, takes a few seconds and may prevent a serious burn.
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Example 2Forklift Tips Scissorlift Over
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Lesson Learned March 21, 2013Forklift Unloading Incident
What Happened?
Two plumbers were placing a scissor lift on the ground level utilizing a rough terrain forklift. When the scissor lift was placed on the ground, prior to the forks being clear of the scissor lift, the employee giving signals climbed into the scissor lift.
The forklift operator began to boom in while the forks were still underneath the scissor lift, causing the tip of the forks to lift up on the side of the scissor lift. The scissor was tipped over on its side.
The employee inside of the scissor lift somehow jumped out of the scissor lift prior to it tipping completely over. There was no injury.
Booming In
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What Went Wrong?The signaler did not ensure that the forks had cleared prior to climbing onto the scissor lift.
The forklift operator shouldn't have proceeded without a signal man. Signals must be used until the entire piece of equipment is clear.
What Can We Do To Keep This From Happening Again?Always finish. Never assume that you are clear. Verify the situation and communicate properly.
In this situation there will be a foreman present at any time a forklift brings material into the building to provide a extra pair of eyes.
SUMMARYThis is an example of what the word “inattention” means. This near miss should have crippled or killed someone. Both individuals involved weren't paying attention to their situation.
By some divine act, the employee on the scissor lift managed to jump out and away from harm. (How many of us think we could do that?).
Always verify that you are clear before continuing to the next thing.
The image shown to the left is not from our incident, is an example of the severity of what happens when a scissor lift is tipped over with a person inside.
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Best Practices for Lessons Learned
• Do the pictures ASAP! If the employees involved are able, and available, and with their well being in mind, get them to demonstrate in the field what went wrong and take pictures.
• Visual – A re-enactment or close to re-enactment of the incident. One or two pictures telling the story without words.
• “Know the Audience” – The crew worker – Keep lessons learned to one page, no more than two. Target information the worker needs to prevent re-occurrence.
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