Learning from incidents involving E / E / PE systems Part 2 - Recommended scheme Prepared by Adelard for the

W Black Blacksafe Consulting This report is the second 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 (this report) presents the recommended scheme and Part 3 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. 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. iii ACKNOWLEDGEMENTS Adelard LLP wishes to acknowledge numerous invaluable contributions to the project from the following people: This report is the second 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 (this report) presents the recommended scheme and Part 3 gives accompanying guidance, examples and rationale. For lessons to be learned from any kind of incident (not just involving E/E/PES), the following processes are necessary: · Incident reporting: workplace staff who witness an incident must report sufficient details for safety managers to investigate further or analyse for trends where and as appropriate. · Incident prioritisation: the recipients of incident reports decide to what extent each incident represents a learning opportunity. A serious incident or accident will obviously require corrective action but there is also much to learn from near misses, especially those that form a recurring pattern. · Incident characterisation and investigation: safety managers analyse selected safety reports and investigate further as appropriate. The aim is to sufficiently understand what happened and generate recommendations to reduce the probability of other incidents with similar causes. The amount of effort spent per incident should be proportionate to the incident's learning potential. Characterisation of incident data is necessary if it is to be …