Learning from incidents
Learning from incidents
Using learning to inform and improve risk management
This national programme wanted to use operational learning to keep national, risk-based, operational guidance up to date. The client needed to be able to collect and combine a quantity of ‘local’ learning, from a variety of sources, in a way that it could be analysed nationally, conclusions drawn, and decisions made.
Using bowtie methodology and software, Gifford James re-created the operational guidance in the form of bowtie diagrams, with additional and specific information attached to each of the hazards and controls. This allows for incident
information, including the performance of specific controls, to be collected in a way that maps to the guidance. The effectiveness of controls, any reasons for partial effectiveness, trends, and hotspots can now be used to maintain national guidance and improve local working practices.
