What many in traditional safety call an 'error,' holds a negative meaning. PPWD Compassionate Safety approach is to challenge this and consider adverse events to be 'any deviation from an expected outcome.' In this way, our investigations become Learning Reviews and can be either pre-deviation or post-deviation.

Learning Reviews

How do you approach an error to generate learning? Learning Reviews have evolved out of Post-Incident Investigations to focus on what went wrong, not who went wrong. Learning Reviews consider:

How we develop a culture of learning.
How we accommodate humans for being human.
How we use compassion to generate safety.

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Learning Review

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"We’ve replaced the old finger-pointing culture of blame with something much more positive, much more inclusive, and much more useful. Hence, we’ve not only moved away from accidents and incidents to learning events, but we’ve also moved away from ‘investigations’ to ‘learning reviews’ too."

Jon Cole, Operations Standards Specialist, Southeastern

The aim of a post-event Learning Review is to understand why has there been a deviation from the expected outcome. A pre-event Learning Review focuses on identifying what could potentially cause a deviation from the expected outcomes. In both cases the aim is on learning and making recommendations that reduce the risk of a deviation occurring or re-occurring.

We have successfully worked with a number of clients to change how they undertake and make sense of investigations.

In arguably our most successful client programme, the client established a post-event Learning Review, and made 21 recommendations - none of which concerned the driver. All recommendations for learning focused on the wider systems around the driver.

Case study

Southeastern

Learning Review for Investigators

Brief: Design and develop a Learning Review for Investigators module, that will enhance the skill set of technically competent investigators.

Solution: It was important that the course focused on shifting investigations from being 'Person' centric to one which encompassed the 'System'.

Result: Recommendations which reach deep into the organisation are now starting to have an effect throughout Southeastern.

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