Over the last few months I’ve had an opportunity to reflect on Operational Risk outcomes in the companies that I’ve worked for and consulted to over the years.  This reflection has led me to identify a major challenge facing us all – Lost Opportunities.

In particular I am thinking that Accident, Incidents and Near Misses are being handled less well than they could be – which means that as Organizations we are missing a golden opportunity.

Before reading further – I’d ask you to reflect. Has your organization ever made the same (or a similar) mistake twice?

Having investigated hundreds of accidents, incidents and production disasters I’d be surprised if your answer wasn’t yes.  I still remember the quote from the lead HSE Investigator on the Piper Alpha disaster in the North Sea – who observed that “There is a terrible sameness in these types of incidents…” alluding to the number of similar incidents that occur before a major loss is suffered.

But –  if you can honestly answer that your organisation has never made similar mistakes twice – please leave a comment on this post and share with others how you’re achieving this!

If you only have a few moments – mouse over the image and it will provide a summary of this series of blog posts using an interactive web system.  All of the post is summarized into a few images, audio and a PDF check list.


Click to access the image in its native application.

This is the first in a series of posts on this subject – and really is intended to help team members and decision makers identify if they have a problem.

Career Highlight – Not Likely!

The vast majority of unwanted incidents that occur in our organizations arise due to Human Error.  The human who made the error is typically someone involved in or responsible for the the task / area where the incident occurred – and this generates a challenge for how things are managed after the event occurs.

Observe a child – or reflect on your own childhood.  If you make a mistake / break something you’re much more likely to try and hide the fact than come clean and tell a parent / adult!

Incident - No Not Really!
Incident – No Not Really!

So – it is Human Nature to try and cover up a screw up.  But it is just this behavior that generates a culture of under reporting and leaving one or more latent error conditions that can cause much bigger problems down the track.

Ask yourself these questions:

  • Who is responsible for reporting incidents and near misses in your organization?
  • Is there a department, responsible role or person in charge of confirming the quality and quantity of reports logged?
  • Does the number of losses report come close to the expected relationship in the Bird Triangle?

It takes a concerted effort for an Organization to overcome under reporting.  A sign you’re winning is when your Organization celebrates its’ successes and looks at problems and incidents as a launch pad to the next successful solution / improvement.

For the next article in the series – why not click here.


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