Learning from incidents involving E / E / PE systems Part 3 - Guidance examples and rationale Prepared by Adelard for the

Abstract

This report is the third of 3 parts presenting the results of an HSE-sponsored research project. The overall purpose is to create a scheme for learning from incidents that involve electrical, electronic or programmable electronic (E/E/PE) systems. Part 1 reviews existing learning processes and causal analysis techniques, examines industry practice and makes recommendations for a new scheme. Part 2 presents the recommended scheme and Part 3 (this report) gives accompanying guidance, examples and rationale. This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy. ISBN 0 7176 2790 X All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. ii ACKNOWLEDGEMENTS Adelard LLP wishes to acknowledge numerous invaluable contributions to the project from the following people: This report is the third of 3 parts presenting the results of an HSE-sponsored research project. The overall purpose is to create a scheme for learning from incidents that involve electrical, electronic or programmable electronic (E/E/PE) systems. Part 1 reviews existing learning processes and causal analysis techniques, examines industry practice and makes recommendations for a new scheme. Part 2 presents the recommended scheme and Part 3 (this report) gives accompanying guidance, examples and rationale. Typical barriers to adoption of any new learning scheme are lack of motivation for the participants, lack of perceived benefits, the implementation cost and the scheme complexity. Participants will be motivated and understand benefits if they are involved in defining the goals of the scheme and its design, and if they are notified of investigation results for incidents they reported and of changes achieved through the scheme. Maximum cost effectiveness and simplicity is attained through building incrementally on existing safety and quality management systems. Only information that is essential for the scheme's identified goals should be recorded and analysed. Three possible stages of implementation are identified (Stages A, B and C). The most important factor in deciding which stage is appropriate for any particular organisation is the organisation's current learning capability. Further customisation will depend on the objectives of the scheme, available resources and existing infrastructure. Example objectives are to reduce workplace injuries, …

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Cite this paper

@inproceedings{HSE2003LearningFI, title={Learning from incidents involving E / E / PE systems Part 3 - Guidance examples and rationale Prepared by Adelard for the}, author={Mark Bowell HSE and Konstantinos Tourlas}, year={2003} }