RAIL TRACK MAINTENANCE CASE STUDY
KEY TAKEAWAY:
Serious near miss/near hit events (such as a safe working irregularity on the rail corridor) are more often than not investigated the same way as when a serious incident involving harm to people occurs. It may be possible to gain richer information about the resilience of controls and necessary changes to systems if we start from the perspective of what went right in such a near miss/near hit event.
Learning from success during projects
While near miss/near hit events and serious incidents present valuable opportunities to learn from mistakes and system deficiencies, our usual approach begs the question. Why do we wait until something has gone wrong or nearly gone wrong to identify potential success? As we have outlined above, success is happening every day! We don't have an incident or near miss/hit every moment of every day. So what do we know about what is happening in between these moments? Beyond audits and inspections that typically focus on deviance from system requirements (again, focusing on failure), the answer is, not very much. We can investigate success when nothing remotely negative has been said to have happened. You have a successful project. The team of people on the project are managing to deliver high performance and have had no incidents or serious near misses. The client's time pressures and budgetary pressures exist in this successful and safe project as much as other projects on your books. What is sitting behind this success? How are the workers managing to achieve that success under those challenging circumstances where others have not? It is worth looking under the bonnet to check out what exactly is powering the engine to accumulate further knowledge and leverage from that to further systematise any of the excellence that you find which may have broader application. What if we started to explore what is happening when things are going right?
Learn
Accumulate
Leverage
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