Sharing Lessons Learned

An electronic newsletter and archive provides Pacific Northwest National Laboratory employees with a valuable tool for sharing safety information and encouraging prevention.

Let that be a lesson to you!" We've all heard that admonition and conveyed it to others, often over and over about the same lesson. Clearly, there is room for improvement in our efforts to really learn from the large and small lessons that life in the workplace presents to us.

Those lessons do not occur in isolation. Workplace safety is inextricably tied to the culture the leadership, management and organization of the entire company. Nor is a safety lesson fundamentally different from any other business lesson.

With these points in mind, Pacific Northwest National Laboratory recast its "lessons learned" program in 2000. The laboratory retained elements of a traditional lessons learned program, such as tracking and trending safety metrics, and added a best practices element to increase staff involvement in creating a safer, healthier work environment.

Today, the Lessons Learned/Best Practices program offers the latest business thinking summarized from current external publications and shares better ways PNNL staff have discovered for doing things. According to PNNL Strategic Planning Director Marilyn Quadrel, the goal is to sharpen the business acumen, project management ability and leadership skills of all staff and to capture the benefits of practices that emerge from lessons learned.

"Lessons learned should not be viewed as specific to a particular discipline or area," she said. "We need to see them in a larger context as part of a long-term strategy to change the way we approach all of our work every day."

Web-Based Sharing

A key tool in the PNNL effort to accelerate learning from past mistakes is one that can be easily implemented by other firms and tailored to their specific needs. It is the weekly placement of Lessons Learned/Best Practices articles in the lab's internal electronic newsletter.

The program is equally applicable in highly regulated environments, such as the national laboratories, and in enterprises that may have fewer external requirements imposed on their operations. And it is cost effective, using less than the equivalent of one full-time person to administer.

Employing yet another Web site to connect with staff could be seen as the lazy way out, but http://pnl.gov/lessons has gradually become an essential part of PNNL's drive to deliver excellence in managing a large DOE research and development laboratory. (See sidebar.)

Stay on Familiar Ground

What makes the laboratory's lessons learned program work? Rather than publishing management admonitions or general industry tips, the articles focus on familiar equipment and situations. "We have a huge variety of operating systems and requirements," said Larry Kimmel, PNNL manager of Quality and Integrated Safety. "When we put lessons learned in the context of our own operations, people can apply them to their own situations."

For example, one article discussed how an evaporation process considered standard by ceramics engineers started a fire in a lab oven, creating a serious situation. Another piece explored an incident in which a researcher was trapped for a few panicked minutes in a 44-degree refrigerated room used to store chemicals.

Lessons learned also help staff become aware of readily available safety resources. After reading about a staff member who suffered cardiac arrest and collapsed unconscious in a hallway, facility managers reported that more employees took the time to locate the newly installed defibrillators in their buildings and learned how to use them.

Up Close and Personal

Most of the lessons learned originate at PNNL and include, with permission, the names and photos of the staff involved. Submissions and readership increased after this practice was initiated by Nancy Metcalf, coordinator of the Lessons Learned/Best Practices program.

Initially there was resistance to using real stories with real names and faces, especially among line managers who always review articles before publication and who were concerned that publishing real incidents would reflect negatively on them. "But they came to see that sharing information helps the whole lab and should be something to be proud of," Metcalf said.

First, Get Their Attention

The Best Practices/Lessons Learned articles shun the terse, jargon-filled language typical of corporate lessons learned in favor of a conversational, narrative style. "I try to tell the story the way you'd do it around the water cooler, while keeping it technically accurate," Metcalf said. She also avoids a disciplinary tone by pointing out everything the staff member did right and presents improvement actions in positive language.

The readable style and specific details help grab the reader's attention. For example, an article about how to respond to a traffic hazard starts with, "Normally, you wouldn't expect to find a wheel lying on the road in the middle of your lane." It goes on to explain an unusual traffic accident an employee experienced and gives tips on defensive driving maneuvers.

Some articles include incident photos to reinforce their message. A lessons learned on electrical burns shows a worker's hand with skin peeled back, exposing raw wounds. According to Vern Madson, a sheet metal worker and the union's health and safety representative, "Seeing these vivid pictures reminds us what can happen and sharpens our safety awareness."

All Hands on Deck

The Lessons Learned/Best Practices articles are accessible to all staff and are linked to a searchable Web site of archived articles. More than half the readers are scientists and engineers who spend a large portion of their time working in laboratory facilities, where risks range from workstation configurations and complicated equipment to chemical, biological and radiological hazards.

When the program started, the articles were sent only to managers and safety personnel, who conveyed them to staff. Now, through the lab-wide newsletter Inside PNNL, the audience is every person at PNNL. Readers can sign up for a free subscription service that automatically sends them articles in their particular areas of interest, such as biological safety, chemical safety, electrical safety and many others.

Managers of PNNL's 12 directorates receive reader statistics every month. They see the number and percentage of ongoing and new readers for all the directorates so that they have a basis for encouraging or acknowledging readership in their groups. These are not Web site hits; they are "stays" on an article of at least 3 minutes.

High Readership

Approximately 65 percent of PNNL's 3,800 staff read the articles on-line or print them out for future reference. Articles are discussed in staff meetings and job planning events, as well as by such diverse groups as technical projects and administrative assistants. Information from several lessons learned articles has been incorporated into training classes.

With this level of readership, PNNL management found a natural partner in the Lessons Learned/Best Practices program to highlight safety issues and showcase solutions through articles on lessons learned, preventive actions, and perhaps most importantly, the common causes leading to accidents.

Management Involvement

Lessons learned also can be a valuable, easily accessed archive. Metcalf recently analyzed the last 2 years of lessons learned as part of an effort to identify the root causes of incidents.

She discovered four factors that can turn a seemingly benign work situation into an accident or near miss. Those factors deadline pressures, inadequate pre-job planning, poor hazard identification and procedure deviation without due consideration of impact were transformed into a separate lessons learned and sent to all staff by the PNNL's deputy director for operations.

The directors of Facilities and Operations and Environment, Safety, Health and Quality (ESH&Q) are planning similar communications on electrical safety and accident/injury precursors.

Focus on Prevention

Prevention is a critical part of the laboratory's strategy to address root causes of incidents. The Lessons Learned/Best Practices program is contributing with an increased focus on prevention overall and a series of topical articles on prevention.

"We need to recognize injury precursors in day-to-day activities at work and at home," said Pat Wright, who supports PNNL's Voluntary Protection Program committee on safety and health. "It could be something as simple as your wrists starting to hurt when your keyboard is improperly adjusted or a backache after heavy lifting in the garden."

In addition, Wright and others are considering how to better integrate lessons learned into work practices so that staff have them for just-in-time learning. Their intent is to deliver lessons learned through standard procedure requirements when people get trained, plan work or grant others access to space or equipment. For example, in an electronic form requiring completion prior to delivery of project funding, project managers now must describe how specific risks will be anticipated and addressed.

EHS&Q director Roby Enge champions the "prevent" approach to work: "I want our people to ask themselves, 'What in this situation could hurt or kill me? And what can I do to prevent it?'"

Improvements in the Works

"We can put these lessons out there, but the challenge is for people to internalize and apply them at work," Metcalf said, noting that management involvement is essential. This commitment is being demonstrated in a review now under way of enhancements to make the program even more useful.

One change will be the expansion of sources for Lessons Learned/Best Practices. "Surely there are important lessons to be gained from industry and other labs that could add value here," said Glenn Hoenes, manager of PNNL's Standards-Based Management System. "We'll also be looking at our own procedures in search of opportunities to mine information about hazards."

Although corporate programs designed to share job-related lessons learned have been around for a while, the PNNL Lessons Learned/Best Practices program is gaining recognition for its innovation. After a conference presentation, leaders of the Society for Effective Lessons Learned Sharing, a national organization for DOE and DOE contractors, praised the program for its personal perspective and practicality, and for providing "the most useful information."

Can one draw a direct correlation between safety statistics and Web-based lessons learned articles? Probably not. However, the Lessons Learned/Best Practices program has significant value in PNNL's ongoing effort to achieve the culture that is essential not only for science and technology excellence but also for the consistently safe work practices through which that excellence is achieved.

Sidebar: At a Glance: Pacific Northwest National Laboratory (www.pnl.gov)

  • A Department of Energy Office of Science laboratory that solves complex problems in energy, national security, the environment and life sciences by advancing the understanding of physics, chemistry, biology and computation.
  • Managed by Ohio-based Battelle since the lab's inception in 1965.
  • Conducts 1,500 R&D projects annually for government and industry in energy, national security, health and environment.
  • Employs 3,800 people including researchers, technicians, skilled crafts persons and professional and administrative staff; $600M annual budget.
  • Staff work in more than 90 buildings, housing thousands of pieces of specialized equipment.
  • For additional information on the PNNL Best Practices/Lessons Learned program, contact Nancy Metcalf at [email protected]

Sidebar: Topical Areas in the PNNL: Lessons Learned/Best Practices Program

Environment, Safety & Health Biological Safety, Chemical Safety, Electrical Safety, Environmental Compliance, Facility Safety, Field Work, Fire Safety, Laser Safety, Nuclear Facilities, Office Safety, Radiological Safety, Respiratory Protection, Transportation and Packaging, Waste Management and Worker/Personal Safety & Health.

General Management Business & Finance, Communications, Computers, Customer Focus, Facility Operations, Human Resources & Leadership, Innovation, Performance Measurement, Policies & Procedures, Project Management, Property Management, Purchasing & Contracting, Quality, Security, Strategic Planning, Travel and Training.

Bryan L. Mohler is manager of integrated planning and assessment at Pacific Northwest National Laboratory. He has extensive experience in the management of high performance research environments, including planning, operations, performance measurement and change management, as well as market research and statistical analysis. Mohler earned both his BA and MBA from Washington State University. He can be contacted at [email protected]

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