{"id":997,"date":"2018-05-17T08:37:36","date_gmt":"2018-05-17T13:37:36","guid":{"rendered":"https:\/\/taocompliance.com\/?p=997"},"modified":"2018-05-17T08:39:22","modified_gmt":"2018-05-17T13:39:22","slug":"learning-from-failure","status":"publish","type":"post","link":"https:\/\/taocompliance.com\/?p=997","title":{"rendered":"Learning from Failure"},"content":{"rendered":"

\u201cFailure is only opportunity to begin again. Only this time, more wisely.\u201d –Henry Ford<\/p><\/blockquote>\n

We often push PSM practitioners to perform Incident Investigations for fairly minor events in the hopes that the lessons learned from those minor incidents will stop the larger incidents from happening. This is, in part, due to CCPS<\/a> (Center for Chemical Process Safety) guidance that, for every single catastrophic accident, there are typically nearly 9,900 minor issues \/ process upsets and 99 near misses.<\/p>\n

\"\"<\/p>\n

So, if you only investigate the catastrophic incidents, then you are only acting on 0.010% of the opportunities available to you to improve your control over the process.<\/p>\n

OSHA has promoted this idea as far back as a decade ago\u2026<\/p>\n

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OSHA and industry have found that when major incidents have occurred, most of these incidents have included precursor incidents. Additionally, OSHA and industry (See CCPS [Ref. 41], Section 5, \u201cReporting and Investigating Near Misses\u201d have concluded based on past investigations, that if employers had properly responded to precursor incidents, later major incidents might not have occurred. Consequently, anytime an employer has an \u201copportunity\u201d to investigate a near-miss\/precursor incident (i.e., an incident that could reasonably have resulted in a catastrophic release) it is important that the required investigation is conducted and that the findings and recommendations are resolved, communicated, and integrated into other PSM elements\/systems so a later major incident at the facility is prevented. \u2026It is RAGAGEP to investigate incidents involving system upsets or abnormal operations which result in operating parameters which exceed operating limits or when layers of protection have been activated such as relief valves. (An example RAGAGEP for investigating incidents, including near-miss incidents is CCPS [Guidelines for Investigating Chemical Process Incidents, 2nd Ed.], this document presents some common examples of near-miss incidents). <\/em>(OSHA, Refinery PSM NEP, 2007)<\/p>\n<\/blockquote>\n

Going a step further, it\u2019s often true that you can learn something about managing complex operations from businesses in entirely different fields. One field that I like to follow \u2013 in part because it\u2019s endlessly re-inventing itself \u2013 is information technology.<\/p>\n

Google recently published an article<\/a> on their Post-Mortem culture, with a farcical worked-example<\/a> that includes the movie \u201cBack to the Future\u201d and a newly discovered sonnet by Shakespeare. The practice of learning from their failures is actually part of their Sight Reliability Engineer handbook and you can read the entire chapter<\/a> if it appeals to you.<\/p>\n

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\u201cFailures are an inevitable part of innovation and can provide great data to make products, services, and organizations better. Google uses \u2018postmortems\u2019 to capture and share the lessons of failure\u2026<\/p>\n

\u2026 For us, it\u2019s not about pointing fingers at any given person or team, but about using what we\u2019ve learned to build resilience and prepare for future issues that may arise along the way. By discussing our failures in public and working together to investigate their root causes, everyone gets the opportunity to learn from each incident and to be involved with any next steps. Documentation of this process provides our team and future teams with a lasting resource that they can turn to whenever necessary.<\/p>\n

And while our team has used postmortems primarily to understand engineering problems, organizations everywhere \u2014 tech and non-tech \u2014 can benefit from postmortems as a critical analysis tool after any event, crisis, or launch. We believe a postmortem\u2019s influence extends beyond that of any document and singular team, and into the organization\u2019s culture itself.\u201d<\/p>\n<\/blockquote>\n

Google\u2019s Pre-Mortem<\/a> Tool \u2013 Anticipating what can go wrong.<\/p>\n

Google\u2019s Post-Mortem<\/a> Tool \u2013 Dealing with what actually went wrong.<\/p>\n","protected":false},"excerpt":{"rendered":"

\u201cFailure is only opportunity to begin again. Only this time, more wisely.\u201d –Henry Ford We often push PSM practitioners to perform Incident Investigations for fairly minor events in the hopes that the lessons learned from those minor incidents will stop … Continue reading →<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[52,6,20,17,65,19],"tags":[61,53,9,10,21,12],"class_list":["post-997","post","type-post","status-publish","format-standard","hentry","category-culture","category-info","category-good-engineering-practices","category-incidents","category-osha","category-system-optimization","tag-incidents","tag-lessons-learned","tag-osha","tag-psm","tag-ragagep","tag-rmp"],"_links":{"self":[{"href":"https:\/\/taocompliance.com\/index.php?rest_route=\/wp\/v2\/posts\/997","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/taocompliance.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/taocompliance.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/taocompliance.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/taocompliance.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=997"}],"version-history":[{"count":1,"href":"https:\/\/taocompliance.com\/index.php?rest_route=\/wp\/v2\/posts\/997\/revisions"}],"predecessor-version":[{"id":998,"href":"https:\/\/taocompliance.com\/index.php?rest_route=\/wp\/v2\/posts\/997\/revisions\/998"}],"wp:attachment":[{"href":"https:\/\/taocompliance.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=997"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/taocompliance.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=997"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/taocompliance.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=997"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}