Learning is a continuous process in life, and there are various learnings, but here we will limit our understanding to safety only. We talk about safety learning - Learning from incidents is essential to the Health & Safety Management System.
Learning from our own mistakes avoids reoccurrence, and learning from others' mistakes avoids occurrences of any similar incident; instead, it is free of cost. Lessons learned are one of the vital tools to improve the safety culture.
During day-to-day life, we keep learning; it is inherent like if you keep a hot glass of water in front of a small kid for the first time, it will touch and recognize, yes, such things can be hot as well. Next time it will not touch even if it is cold. Looks funny, but this is the reality. The child learned from their mistake.
Accordingly, this safety course is developed to spread a systematic approach to lessons learned from incidents. With various topics and subtopics and intermittent quizzes, we will try to understand the following key aspects, such as
Lessons Learned Process, including
- What is Learning from incidents?
- Why do we need to learn lessons?
- What is effective Learning with elements of Learning
We will analyze a case study of the actual Incident Hazira gas plant fire. The incident happened on the 24th of September 2020 at one of the Gas Processing plants in India: ONGC (Oil and natural gas company), situated at Hazira in Gujarat near the city of Surat.
We will discuss
- Incident summary
- PEAR Loss (means a loss in terms of People, Environment, Assess & reputation) including Brief on Plant and processes
The course will include the significant part that is What went wrong? We will discuss PSM (Process Safety Management System) and its 14 elements and map incident findings concerning each element. So that we can understand, we can identify the gap and act accordingly.
We shall also discuss the Cause & Root Cause of the incidents, and an essential aspect is How to avoid them in the future? By discussing the investigation Committee's recommendation
At the end of the course, we will discuss Missed Opportunities by commenting on the investigation process and how this could be better.
And finally, we will conclude the session with a bonus for participants and provide downloads of training material so that you can percolate this Learning as relevant.