Two questions to improve organizational learning from safety events

Two Questions to Improve Organizational Learning from Safety Events

By Eric Michrowski

The true implication for an organization that isn’t seeking every opportunity to learn is to accept to operate with a certain level of ignorance. Such comfort with organizational ignorance is one of the biggest barriers to success for businesses and is particularly dangerous when it comes to organizational safety. Companies need to, without compromise, learn from small events, near misses and injuries in order to systematically remove potential risks and reduce SIF potential. This is why leading organizations work to create an environment where workers are comfortable reporting close calls and incidents. 

By focusing on using near misses and even human error as learning opportunities, organizations can implement changes to the system and avoid serious events. Blaming the employee is convenient, not effective. It means that any incident can be written off as an individual mistake instead of the result of unsafe factors in the environment and/or a flawed system, and nothing gets fixed in the end.

Very few serious injuries and events have root causes that are new. Usually, accidents are caused by a combination of “small” events that inevitably end up creating a bigger situation. Look at scenarios like the Three Mile Island nuclear meltdown, where all of the circumstances leading to the accident had occurred before, but never at the same time. Thus comes the importance of reporting mistakes and near misses and addressing them in a serious and timely manner, no matter how insignificant an incident may seem or how tedious addressing it will be. The more we learn about events that never caused a significant event, the more likely we are to reduce the chance of an actual event happening.

As CEO of Alcoa, Paul O’Neill famously prioritized safety above all else, a philosophy that was unprecedented at the time. O’Neill made sure that if an incident took place at an Alcoa facility, no matter where in the world it happened, he would be briefed on the issue less than 24 hours later. This is pretty incredible when we consider the limits of international communication back in the 80s. We can all be inspired by O’Neill’s strong desire to learn from every event and drive constant improvement.

Effective questions for continuous learning

The U.S. military makes a point to do After Action Reviews with the goal of learning from events and continually bettering performance. It’s important to sit down with your team on a regular basis to discuss pitfalls and possible improvements, as well as pinpoint which strategies worked and should be maintained. 

Consider using these relevant questions in your discussions with your leaders and team members:

  • What learnings can we take from the {last injury} to reinforce ownership of safe choices and practices? How did we reinforce the learnings with our team?
  • When did the last near miss occur? What did we learn from it? What changes did we implement as a result?

Asking these types of questions ensures that when something happens, the situation is analyzed and root causes are addressed to prevent future incidents.

Check out more effective questions to leverage with your team members here.

At Propulo, we help leaders develop their safety leadership commitment and create a learning organization.


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To create psychological safety AND drive results, lead with wise compassion