WHY CAN'T WE LEARN FROM OUR MISTAKES LEARN THE LESSON TELL THE STORY

Conference · Thu Feb 03 04:00:00 EST 2005

OSTI ID:837167

LANGSTAFF, D C ^[1]

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1. DOE-RL

Tell the story well and people can learn from the lesson. The United States Department of Energy (DOE) Office of Environmental Management (EM) and its contractors are pursuing environmental remediation at the Hanford Site. This endeavor has been underway for a number of years, both at Hanford and at other sites across the DOE complex. Independently, the occurrence of two fatalities on two Sites at opposite ends of the country within two weeks raised the question, ''What is going on in the Field?'' Corporate EM management communicated directly with Field Office Managers to answer the question. As a result of this intense interest and focused communication, EM identified four areas that need additional exploration. One of those is, ''EM's ability to learn from its mistakes.'' The need to cultivate the ability to learn from our mistakes is not unique to DOE. A quick review of EM Lessons Learned reports shows that most of the reports in the EM system originate at the sites with the largest budgets doing the most work. A second look, however, reveals that many reports are repetitive, that many people might consider many reports trivial, and that reports on some of the more significant events sometimes take a long time to get distributed across the DOE Complex. Spot checks of event reports revealed frequent identification of symptoms rather than root causes. With a high percentage of identified root causes in the questionable category, it is highly unlikely that the real root causes of many events are being corrected, thus leading to recurrences of events. To learn the lesson from an event, people need to be aware of the root causes of the event. Someone has to tell a story the reader can learn from, i.e., include all the information needed to understand what happened and why it happened. Most importantly, they need to understand the lesson to be learned.

• Research Organization: DOE-RL (US)
• Sponsoring Organization: ENVIRONMENTAL MANAGEMENT (US)
• DOE Contract Number: AC06-96RL13200
• OSTI ID: 837167
• Report Number(s): DOE-0306-FP, Rev.0
• Country of Publication: United States
• Language: English

Related Subjects

29 ENERGY PLANNING, POLICY, AND ECONOMY
ACCIDENTS
DEATH
INFORMATION DISSEMINATION
NUCLEAR FACILITIES
OCCUPATIONAL SAFETY
REMEDIAL ACTION
US DOE