Organisational learning and continuous improvement
Establishing an effective learning culture is vital for the safety culture and performance of an organisation. Incidents and failures are seen by organisations with good safety cultures as valuable opportunities to improve operations, rectify unsafe conditions and learn lessons to avoid more serious events. It also shows commitment to improvement and allows employees to actively participate in the continuous improvement process. Organisational learning includes:
- in-depth root cause analysis and learning from accidents, incidents & near misses;
- soliciting and responding to ideas from employees;
- providing timely feedback and sharing of information across the organisation.
It also includes:
An effective reporting culture recognises that human error – which is an integral part of most ‘systems’ – needs to be monitored proactively in the interests of continuous improvement.
Good quality (leading and lagging) indicators can provide feedback on key organisational behaviours. Some examples are:
- number of suggestions for safety improvements
- perceptions of management commitment to safety
- safety policy published
- number of safety tours carried out
- percentage of improvement solutions actioned/closed out
Employees need to be encouraged and willing, even rewarded, for coming forward and reporting essential safety-related information (ie. errors they have made; behaviours they have observed) without fear of sanction. This crucially depends on how an organisation handles blame and punishment and the building of an atmosphere of trust.
A ‘just’ culture – which strives for fairness – is essential to help an organisation learn and strengthen its safety culture. This may be apparent in the way an organisation responds to the reporting of incidents and near misses.
In a just culture, the company line is more clearly drawn between acceptable (non-culpable) & unacceptable (culpable) behaviour (ie. clear statement in Company Safety Policy) so that appropriate action can be taken to prevent a recurrence. Based on an understanding of human factors, unintentional unsafe acts (ie. honest errors, routine and situational violations) are seen as opportunities for organisational learning. Conversely, deliberate, intentional unsafe acts (ie. reckless non-compliance, criminal behaviour, substance abuse and sabotage) are dealt with accordingly, with the required level of sanction.