INSTITUTIONAL MEMORY
Most accidents do not occur because we do
not know how to prevent them but because we do not use the information that is
available. The recommendations made after an accident are forgotten when the
people involved have left the plant; the procedures they introduced are allowed
to lapse, the equipment they installed is no longer used, and the accident
happens again. The following actions can prevent or reduce this loss of
information.
•
Include a note on “the reason why” in every
instruction, code, and standard, and accounts of accidents which would not have
occurred if the instruction, code, or standard had been followed.
•
Describe old accidents, as well as recent ones,
in safety bulletins and newsletters and discuss them at safety meetings.
•
Follow up at regular intervals (for example,
during audits) to see that the recommendations made after accidents are being
followed, in design as well as operations.
• Make sure that recommendations for changes in design are acceptable to the design organization. On each unit keep a memory book, a folder of reports on past accidents, which is compulsory reading for new recruits and which
•
others dip into from time to time. It should
include relevant reports from other companies but should not include cuts and
bruises.
•
Never remove equipment before you know why it
was installed. Never abandon a procedure before you know why it was adopted.
•
Devise better information retrieval systems so
that details of past accidents, in our own and other companies, and the
recommendations made afterward are more easily accessible than at present.
•
Include important accidents of the past in the
training of young graduates and company employees.
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