“The only real mistake is the one from which we learn nothing.” John Powell
Return of Experience (REX) is a key process for safety continuous but sometimes, people believe that it is time consuming and doesn’t enough efficient. Sometimes it can perceive as constraint. However, it is a virtuous cycle: you must capture the maximum of events, perform the analysis of those events, find root causes and finally improve your safety system.
You must answer to simple and essential questions:
How to catch the events?
How to analyze the events?
How to find the root causes?
How to improve the safety system?
And globally:
Why, How, When, Who, What benefits do you expect from the REX process?
However, you may need to question some of your certainties.
For the first question: "How to catch events? "
It is obvious that accidents with or without lost time, first aids are identified but do you catch near misses, deviations, unsafe acts, unsafe conditions, lack of training, missing safety briefing or safety meeting; dedicated to safety, no respect of procedure?
More globally, do you have a transparency culture, a just and fair culture, balance between recognitions and discipline, what is the culture of your management ?
For the question "How to analyze your events? "
More important that How, it is essential to answer to the WHO.
Who is in charge of the analyse and specially how management is involved?
It is important to have clear and defined process and to define the participants of the analysis.
For the question "How to find the root causes?"
There are many tools to find the root causes: the 5 whys, the 5, 6 or 7 M, the trees causes, ...
But the key question is: “do you want to find the root causes? “
Unfortunately, the analyses are too weak ! An accusing finger is pointed at the individual responsibility and behavior of one or more people.
Remember: To point an accusing finger at an individual is to have three fingers pointing back at you.
Three fingers pointing back at you represent:
- Organization and the heart of collective labour relations
- Management and mainly at the top management
- Safety system at local and global level
Globally, the culture of the company and its values
Finally, for: "How to improve the system?"
For many cases, you will implement SOP, working instructions, operating mode, rules, is, procedures, training. It is also obvious that it must be linked with root causes to define the corrective actions and preventive actions. Be aware: an excessive approach can lead to a complexity of the system by the multiplication of procedures, sometimes contradictory or not applicable in an effective manner.
Looking forward to discussing in more detail
