Como você lida com incidentes de segurança de processo e aprende com eles?

Lidar com incidentes de segurança de processo envolve um conjunto estruturado de ações para identificar, responder, analisar e aprender com o evento, visando evitar a repetição e melhorar os processos de segurança. Aqui estão as etapas mais comuns: Aqui estão as etapas mais comuns: 1. Resposta Imediata ao Incidente. 2. Investigação do Incidente. 3. Correção e Melhoria 4. Documentação e Comunicação 5. Lições Aprendidas e Melhorias Contínuas A chave para o aprendizado a partir de incidentes de segurança é ter uma abordagem proativa, documentada e focada na prevenção de futuras ocorrências.

It will be possible to report incidents and near misses more quickly if the criteria for classifying them are made clear. This will have the following advantages: - Preserving evidence that must be kept updated. - Getting witness statements as soon as memories start to fade. - Fulfilling organizational and legal obligations.

By following these steps, organizations can effectively handle process safety incidents, learn from them, and strengthen their overall process safety management system. Immediate Response Containment and Mitigation Incident Investigation Root Cause Analysis Corrective Actions Communication and Reporting Learning and Knowledge Sharing Continuous Improvement Monitoring and Follow-Up Feedback Loop

It is important to develop and establish a reporting system. This system should enable us to record near misses and small incidents as well as preliminary reports of major incidents. There should be a standard form for that purpose and it is definitely helpful to fill and save these forms online for better access and sharing purpose.

Promptly reporting incidents is paramount to effective incident management. Following the emergency response plan and promptly notifying relevant parties ensures swift action and minimizes potential harm. Documenting incident details systematically is crucial for accurate analysis and future prevention. Utilizing standardized incident report forms fosters consistency and ensures all pertinent information is captured. This structured approach facilitates thorough investigation and enables organizations to glean insights for enhancing safety measures. Timely reporting and comprehensive documentation lay the groundwork for informed decision-making and continuous improvement in incident response and prevention efforts.

Investigation should be done following a standard approach already defined in your organization. Depth of the investigation should be determined risk-based. A more significant accident with higher risk level needs a more complex and detailed investigation.

It is necessary to create and implement a defined procedure to look into process safety incidents and near misses to ensure: - A well implemented and documented process safety incident investigation system will offer a standardized and repeatable method for gathering data, examining and determining contributing elements, pinpointing fundamental causes, and formulating recommendations. - Having an effective incident investigation mechanism in place should help to guarantee that lessons are taken away from the process and utilized to promote safe and dependable operations.

Investigation and analysis of process safety incidents are essential for understanding root causes and contributing factors. This thorough examination helps prevent similar incidents in the future by addressing underlying issues within the system. It provides insights into weaknesses in procedures, equipment, or human factors, enabling targeted improvements. Effective investigation and analysis also contribute to regulatory compliance and organizational credibility, fostering trust with stakeholders. Neglecting proper investigation and analysis can perpetuate recurring incidents and undermine safety culture and performance.

The 5 Why method is a way of implementing incident analysis which is originally developed in the 70’s by Sakichi Toyoda and was later used within Toyota Motor Corporation during the evolution of their manufacturing methodologies. It is a simple but effective method to find the cause of incidents. The 5 Why method is a question-asking method that is used to understand the cause/consequence relationships that underlie a particular problem. The ultimate goal of applying the 5 Whys method, is to determine a root cause of an event or problem. The idea is to ask the question why the event happened and to ask why for that answer as well until you reach the root cause of the event.

Conducting a thorough investigation is critical for uncovering the underlying causes of incidents. Gathering and preserving evidence, including documentation and eyewitness accounts, is essential for an accurate analysis. Employing proven methods such as fault tree analysis ensures a systematic examination of causal factors and barriers. Collaboration with a multidisciplinary team and subject matter experts enhances the depth and accuracy of the investigation. By identifying root causes and contributing factors, organizations can implement targeted corrective actions to prevent recurrence and strengthen safety protocols. Effective incident analysis fosters a culture of continuous improvement and enhances overall safety performance.

Incident investigation recommendations or action items could be categorized based on the cause type: - actions to address immediate causes - actions to address contributing causes And finally and most importantly, actions that are systemic and addressing the root causes of the incident.

The investigation team should identify the fundamental causes and any contributing causes, formulate initial suggestions to address them, and resolve these recommendations to provide final action items by: - Avoiding disciplinary or other human resources-related action - Addressing all of the root causes. - Avoid making recommendations that are ambiguous or incomplete. - Entering the recommendations into the organization's incident identification system, or alternatively, the tracking system - Resolving suggestions with the aid of technical reviewers - Recording the actions to address the recommendations. - Monitoring and overseeing the last-minute action items - Implement given actions to lower risk and avoid repetition.

Recommendations raised against investigations should be carefully evaluated for feasibility, effectiveness, and alignment with organizational goals. Implementation should involve assigning clear responsibilities and timelines to ensure accountability. Regular monitoring and review of progress are essential to track the effectiveness of implemented recommendations. Additionally, fostering a culture of continuous improvement encourages proactive identification and implementation of preventative measures. Ensuring adequate resources, training, and support for implementation efforts is critical for success.

Communicating and sharing the learnings of incident reports is vital for organizational knowledge dissemination and improvement. Utilize various channels such as meetings, newsletters, or online platforms to reach all relevant stakeholders. Emphasize key insights, lessons learned, and actionable recommendations derived from the incident investigation. Encourage open discussion and feedback to foster a culture of learning and continuous improvement. Regularly revisit and reinforce these learnings to ensure they are integrated into daily operations effectively.

Sharing the incident investigation findings should be done using multiple methods: - sharing summary of the findings - sharing the full report - making animation or video clips from the incident sequences

There are several great responses on how to communicate findings already posted here so I won't repeat those tips. However, I want to add that it is very important to continue sharing lessons learned from incidents over time. Often referred to as "tribal knowledge", this information disappears from the collective employee history over time. It is important to have an established communication channel to revisit lessons learned over time from your organization and others.

Create a formal procedure for informing relevant internal staff members whose jobs will be influenced by the lessons gained from incident investigations. This procedure should include ways to communicate the lessons to the staff, such as in-person briefings, regular forums like safety meetings, the use of e-mail systems to communicate the lessons to the appropriate staff, or other means. Documentation of what was shared, when it was shared, and who received it should also be included in the process. Establish a procedure for informing pertinent outside groups of the lessons learnt from event investigations. "External organizations" might refer to both organizations outside the corporation and other branches.

Important is to thank the Person who had responded and informed you for his feedback. Otherwise your input will dry out and your learning comes to a standstill.

A culpa não é útil para ninguém. Vejo muitos gestores aqui na rede falando sobre responsabilização: o funcionário que não usa EPI deve ser desligado. Mas o que seu time está aprendendo com isso? Sugiro avaliar as falhas e sucessos para compreender o próprio sistema e como ele contribui para as condições que permitem o erro. O objetivo é estabelecer uma responsabilidade voltada para o futuro, promovendo melhorias no sistema ao longo do tempo. Veja que, nessa abordagem sistêmica, buscar um culpado não vai te levar a lugar algum. Deveríamos focar nossas energias em aprender com os erros e promover a responsabilidade para aprimorar o funcionamento do sistema no futuro.

Learning from incidents is paramount to preventing their recurrence and improving overall safety performance. Disseminating incident findings and lessons learned throughout the organization ensures that similar processes or situations are safeguarded against similar risks. Training and educating staff and stakeholders on incident causes and corrective actions cultivate a culture of continuous learning and improvement. By instilling a mindset that embraces learning from mistakes, organizations can proactively identify and address potential hazards, bolstering their resilience and enhancing safety outcomes.

Process safety incidents are managed through thorough investigation, root cause analysis, and corrective action implementation. For instance, in renewable energy projects like offshore wind power, incidents such as turbine failures prompt investigations to improve design and maintenance protocols. In manufacturing and battery storage, incidents like chemical leaks lead to process adjustments and training enhancements. Grid code compliance studies ensure incident prevention through regulatory adherence and system optimization. Learning from incidents fosters continuous improvement and risk mitigation.

Firstly, we have incidents due to control/s failure or a lack of control/s... After implementing new controls or improving the existing controls, we share the lessons learned from it. I should then take some time to ask those who are most affected by the incidents and the leadership team the following 2 questions: 1. Where else in our plant/operation can a similar incident happen? 2. How will we know the interconnected barriers to the main controls effective? Finally after incident data trend analysis, I should then turn the data from incidents of similar type into new knowledge and also share and ask every individual to apply... Learning is the easiest part, but the application of key learnings is the hardest part