The Failure Modes

Organisations investigate diligently and then repeat the incident. The break happens at identifiable points.

The failure modes

• Findings that are too general. "Improve communication" cannot be implemented and nobody can tell whether it was.
• Distribution without absorption. An alert emailed to a distribution list is distributed, not learned.
• Weak actions. A procedure update and a briefing satisfy the action list without changing the conditions.
• No verification. Actions closed on completion rather than on evidence of effect.
• Knowledge loss. The people who understood the lesson move on and nothing durable records why the control exists.
• Local learning only. The site where it happened improves; the identical plant elsewhere does not hear about it.
• Dismissal. "That could not happen here" — the most common response to an external alert and almost always wrong in some respect.
• Volume. So many alerts are issued that none is read.

Distributing a lesson is not learning it. Learning is visible in what people do differently, and in what is physically different.