In repsonse to “Closed lessons loops, examples from a lessons database”

I recently posted this response to a Knoco post on Closed lessons loops, examples from a lessons database.

Enjoy reading both posts, interested in your views…

Hi Nick, like the post. I agree with your views…My PhD lessons learned research has taken me down the safety lessons learned connection (safety culture, just culture etc). On another well known incident, I recall the review of the BP Deepwater Horizon accident investigation revealed how lessons learned of previous “well control event incidents” and “lines of communication” were not acknowledge or addressed and was a contributing cause to the failure (BP 2010, Deepwater Horizon Accident Investigation Report: Cleveland, C 2011, Macondo: The Gulf Oil Disaster, Encyclopedia of Earth, http://www.eoearth.org/article/Macondo:_The_Gulf_Oil_Disaster?topic=64403).

I understand that NASA uses the BP Deepwater Horizon incident as a lessons learned case study paying particular attention to communication deficiencies around government oversight, disregard of data, testing, changes to process, safety culture and lessons learned from previous incidents (NASA 2011, The Deepwater Horizon Accident: Lessons for NASA, Academy of Program/Project & Engineering Leadership, http://www.nasa.gov/pdf/592629main_BP_Case_Study_29AUG2011_FINAL.pdf).

I would appreciate your views on how high reliability organisations operate and their connection with organisational learning by addressing safety problems. They seem to have a flexible and informed reporting systems with a strong commitment to a safety just culture environment. How do we transfer this approach to safety into operational and project management lessons learned?

Regards, Stephen


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