Learn from the “gift of failure” ; event analysis and organisation learning hold the key to mitigate the risk in coal mines

In mines we come across hundreds of hazards and meet different incidences which may sometimes turn to serious or fatal accident .The whole approach always on the line of regulatory compliance while taking precaution or damage control when accident already occurred. But if we just tweak the whole approach in another dimension ie to learn from this failure with systematic or event analysis then we will consider these incidence are the” gift of failure” where we can initiate a process to refine the operational or structural process(operational, organisational or mental) of working engaging all the stakeholders in more safer procedural framework. The whole process can be continuous iterated in three nodes of improvement event analysis , organisational learning and learning at different levels. In the system failure Normally after any disaster or accident with deep impact on safety it takes years to frame and incorporate the norms and regulation , laws and bye laws by the investigating agencies. But for the daily operation in different sector as mining where the hazards are more intense the approach of organisation learning at different level as well as event analysis will be always more result oriented. The event analysis not only prevents further problem but due to its cross functional analysis or perspective looking is concerned , there will be assured development of trust and relationship inter disciplinary and inter organisations(the machine suppliers , the operators and the regulators). Normally when there occurs an accident in mine , we more often get obsessed with finding the guilty , initiating the blame game by trying to procure data or information on ad-hoc basis which again inhibit the right ambience of learning. Here needs balancing the both one is reconstruction of events one by one peeling over the layer as well as system thinking. Now if we understand the event analysis is itself a learning experience , we will again miss the forest for the trees. So whether assigning liability, minimizing disruption, improving productivity, increasing safety all are the intent of investigation , still learning needs different sort of approach like documenting or capturing and retrieving when needed. Here we need empowerment of every level to speak up their mind , their thinking. It’s happened that sometimes just invoking pressure from the externalities like regulator or other stake holding agencies initiate the process of learning followed by will to change. Now normally we see in most of the investigation of the incident or accident in the mine , the mental model or the causal relation of different actors causing the incident which need to be handled with time and tool by the manager, regulator, other stakeholder. In any case by mismanaging or missing the feedback /mental model based on system thinking(may be due to fact they are too busy, over confident, with rigidity in mind, obsession, prejudice ) we will again miss the scope of learning from the incident. This type of approach will definitely help to pave the way for more learning and that too from small and distant incident if we pick up the right approach of system thinking . It will be more proactive and we need not be waiting for the gift of the failure ie one accident or incident to get ourselves rectified. Recently in mines we are deploying the automated systems like fleet management system or OITDS , different smart system as well as new machines with high sophistication electronically and operatively. With this system or IT application our vulnerability now being exposed to system failure to high degree which can put the operator or the employees as well as our other assets like machines etc at stake. It’s a way to push the envelope of safety more and more susceptibility induced by internal fault as well as error in design or externalities. So the need to understand and learn from failure gets multiplied more and more as we transform to process enabled organisation from discrete functioning.

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