CENTRE FOR LESSONS LEARNT - THE NEXT GENERATION

EXECUTIVE SUMMARY

There has been two primary means to manage the lessons learnt an Access data base was initially established followed by a Risk Management data base both of these have their own limitations in their current form.

In reviewing Lessons Learnt processes, discussions with Missions Centred Solutions USA, other international papers and interstate processes. It is apparent that an opportunity prevails to improve operations of the Centre for Lessons Learnt and management of issues across the entire organisation.

It is recommended that the previous access data base be modified to meet the process needs identified in this paper.

BACKGROUND

CFS has espoused to be a learning organisation and implemented a Centre for Lessons Learnt process. A committee and process for continuos improvement had previously been adoptedto improve our systems of work resulting from operational debriefing, After Action Review’s and a number of investigation processes. However it is apparent that thereis a culture within the organisation which expects someone else to address the problem nor is there accountability for recommendations and in the majority of lessons policy and training being the primary treatment methods.

An examination of existing processes have highlighted a deficiency in the centre for lessons learnt processes, existing systems of work did not clearly analyse cause, articulate responsibility at the local level or identify treatment options.

The organisation requires a clear process where issues are dealt with at a local level,this is identical to the OH&S process, and that a process of analysing cause, allocation of responsibility to resolve the issue and ability to track and record status and achievement.

Personal discussions with Mission Centred Solutions,USA., identified that the majority of issues can be assigned to a number of human factors. This is also consistent with James Reason’s Swiss Cheese philosophy.Drawing 1, and in a number of books on Crew Resource Management. As result of this analysis requirements for the data base is outlined in Appendix 1.

OBJECTIVES

The overall objective is to refocus the learning culture within CFS by July 2009.

Other aims are to:

  • Implement a clear process of managing issues (Lessons Learnt) recommendations and findings, identifying cause, assigning responsibility and reporting against lessons learnt.
  • Re-establish the debriefing process to enable issues are first resolved at a local level together with the AAR process.
  • Establish CFS as a benchmark learning organisation.
  • For the CFLL process to be promoted across the entire organisation resulting in acceptance and willingness to share learning’s.

STRATEGY

To achieve the overall objective there is a need to re-engineer the debrief process to ensure issues are resolved locally and immediately post event. This is outlined in the paper titled Improving Local Debriefing, 2009, Kearney B.

The access data base be amended to analyse cause, attribute human factors to issues, identify recommended treatment options and assign responsibility as well as determining risk. Although some of these processes already exist communication and responsibility/ownership is not accepted across theorganisation and will be a major task over the forth coming months.

Process

  1. Executive agreement
  2. Strategic Leadership Agreement
  3. Modification to access data base
  4. Communication with staff and volunteers

Outcome

  1. The CFS is refocused as a learning organisation and has a process which is transparent to stakeholders.
  2. That lessons learnt are linked to annual business plans.
  3. That CFS develops a communication plan to stakeholders and volunteers sharing lessons learnt.
  4. That a open and sharing and learning culture is developed within CFS

Proposed process for Centre for Lessons Learnt

Data base heading / Input / Comment
Reference Number / Registration number only
Date / ##/##/####
Incident Number / CFS incident number
Do we need to report by one Incident?? / Links issues with incident
Source Document / Report
Debrief
Investigation
External report/investigation
Coronial recommendation
Case Study
Other / Link back to origin
Isn’t this the actual Document Library?
Observation / Free text
Previous software linked Issues to each other?? / Brief statement of what was observed, personal opinion
Description / Free Text / Text outlining situation or providing background to observation
Theme / Organisational factors
Unsafe supervision
Pre-conditions for unsafe acts
Unsafe acts
Individual failure / Enables sorting by major grouping. Human factor classification.
Cause / 1. Sensory Perception
Misjudgements of distance, clearance, speed, etc.
Conditions that impair visual performance:
Featureless terrain (such as a desert, dry lake, water)
Loss of situational awareness
Failure to predict or anticipate changing conditions
Failure to respond to communication or warning
Excessive crew stress or fatigue
Excessive workload or tasking
Inadequate briefing or preparation
Adverse meteorological conditions
2. Medical and Physiological
Incompatible physical capabilities
Influence of drugs or alcohol
Heat/ Cold
Excessive personal stress or fatigue
Inadequate nutrition or dehydration (such as omitted meals)
Contaminated or Toxic Atmosphere
Other medical or physiological condition
Medical or physiological preconditions (health and fitness, hangover, dehydration,)
3. Knowledge and Skill
Inadequate knowledge of systems, procedures, etc. (knowledge-based errors)
Used improper procedure
Inadequate experience for complexity of assignment
Misuse of procedures or incorrect performance tasks (rule-based error), such as:???
Failure to conduct step(s) in prescribed sequence
Conditions that lead to inadequate operational performance: ???
Inadequate essential training for specific task(s)
Inadequate recent experience or inadequate experience
4. Assignment Factors
Poor communication with other assets (such as ground or aircraft)
Inadequate or faulty supervision from ground or tactical aircraft
Changing plans tactics (change of teams on incidents)
Deviation from procedures
Demonstration of inadequate performance or documented deficiencies
Inadequate training or experience for specific task(s)
Adverse weather conditions
Changes in fire behaviour ??? where is 5
6. Judgment and Risk Decision
Acceptance of a high-risk situation or assignment
Misjudgement of assignment risks (complacency)
Failure to monitor assignment progress or conditions (complacency)
Other
7. Communication and Crew Coordination
Inadequate assignment plan or brief
Inadequate or wrong assignment information conveyed to crew
Failure to communicate plan or intentions
Failure to work as a team
Inability or failure to contact and coordinate with ground or aviation personnel
Inadequate communication or failure to acknowledge communication
Interpersonal conflict or crew argument during assignment
Conditions leading to inadequate communication or coordination:???
8. System Design and Operation
Use of wrong switch or lever or control
Misinterpretation of instrument indication
Inability to reach or see control
Inability to see or interpret instrument or indicator
Failure to respond to warning
Inadequate system instructions or documentation
Inadequate system support or facilities
9. Supervisory and Organisational
Not adhering to rules and regulations
Inappropriate scheduling or crew assignment
Failure to monitor crew rest or duty requirements
Failure to correct inappropriate behaviour
Failure to correct a safety hazard
Failure to establish or monitor quality standards
Failure of standards, either poorly written, highly interpretable, or conflicting
Risk outweighs benefit
Poor crew pairing
Excessive assignment tasking or workload
Inadequate assignment briefing or supervision
Failure to perceive or to assess correctly assignment risks, with respect to:???
Hazards go unseen or unrecognized
Environmental hazards or operating conditions assignment tasking and crew skill level
Equipment limitations
Conditions leading to supervisory failures:???
Excessive operations or organisational workload (imposed by the organisation or imposed by Organisational chain)
Inadequate organisational safety culture
Inadequate work standards or low performance expectations
Inadequate or bad example set by supervisors
Inadequate safety commitment or emphasis by supervisors
Organisation lacked an adequate system for monitoring and correcting hazardous conditions
10. Maintenance
Procedures
Unwritten
Unclear or not defined or vague
Not followed
Records
Discrepancies entered but not deferred or cleared
Entries not recorded or not recorded in correct book(s)
Improper entries or unauthorized signature or number
Falsification of entries
Publications, manuals, guides
Not current
Were not used for the procedure
Incorrect manual or guide used for procedure
Not available
/ Standard reference list which enables sorting. Identifies common themes to events or observations.
Sequence?
Risk / Risk Table
Likleyhood
Consequence
= Risk Rating
Reference Aust Standard ??
No report by Risk Rating
Single Variant ??? / Assesses risk of an issue. Assists in prioritising treatment.
Action Recommendation, Lesson Learnt / Free text / Statement describing lesson to be learnt.
Treatment Tool / Elimination
Substitution
Administration
Operations Bulletin
SOP
COSO
Review of Training skill knowledge
Review of Procedure
Email
Case Study
Investigation
Hazard Alert
Operational Update
Web info release
Committee review/consideration
Engineering
Technical assistance
Protective
Scenario testing
Survey
Other
Fire Ground Practice
Equipment upgrade/replacement
Discharge not valid
/ Provides guidance as to how lesson will be managed
Multi-select?
Is this tied to the Action, or the Issue?
Responsible Officer / Chief Officer
Deputy Chief Officer
Manager Operations Services
Manager Operations Planning
Manager Training
Manager I& L
Manager Prevention
Manager Operational Improvement
Regional Commanders
Regional Operations Planning
Regional Training
Manager Strategic Services
COAC
OH&S
SAMFS
Police
SES
Other Agency
Other
/ Enables issues, lessons learnt to be assigned to a person
Multi-select?
But each action is assigned to a different person and thefollow up and status is on each action, as well as Issue.?
Status / Assigned and actioned
Assigned no action
Investigated
Issues accepted
Discharged no valid issue.
Referred to a person
Referred to external organisation
Seeking consultation
Seeking approval
Completed / Records status and progress, enable tracking and reporting orf progress.
Should this be a plan with target dates – like a Microsoft Project chart??
Date / ##/##/#### DUE DATE ??? and what default?? / Records status
Evidence of Control of lessons learnt / Free text
This looks like a summary at the Issue level of all of the outcomes of actions? / Description of implementation of lessons eg Training TRK’s amended. Operational Bulletin distributed xx/yy/zz
Key Phrases / Free text. Short phrases or words
Both Issue and Action? / Terms provide clarification of where lessons exist in organisation or linkages with other functions, sections or lessons.
Assists in clarifying issue or lesson learnt.

NO report by Risk Rating

Report formats

By

  1. Responsible person- list of issues. Reference number date, status
  2. Theme – assembly of issues by theme provides indication of major areas within CFS of contributing factors
  3. Summary of issues by treatment tool
  4. Lessons learnt and Evidence of control – Report which provides evidence of closure of lessons learnt

Entry point into CFLL Access data base.

Entry point into Risk register for CFLL

Drawing1. Reasons Swiss Cheese model.

Status: DraftPage 118/10/20188:51:40 PM

Centre for lessons Learnt Next generation v3.doc

C:\Data\DevSites\CFS\Lessons Learned\Centre for lessons Learnt Next generation v3.doc

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