Sharing Lessons Learned from Incidents/Обмен опытом, извлеченным из инцидентов

Издание на английском языке
The shipping industry has worked hard in recent years to eliminate personal injuries and reduce damage to the environment and assets. Though we have taken big steps towards ensuring that each day ends safely for everybody in our industry, we still need to do more.
In particular, we must make sure that we learn the lessons from incidents. Following any incident, we have programmes and procedures for investigating what happened and why. The point of this work is that we learn from what happened and do all we can to ensure it doesn’t happen again.
This information paper outlines the most effective ways that vessel operators can share the lessons that we learn from incident investigations.
It focuses on three levels of sorting and sharing the lessons learned from incidents, and it suggests formats that you can use to record and organise the information.

Contents
Purpose and scope
Contents
Glossary and abbreviations
1 An introduction to the guidelines
1.1 Background: why we need guidelines
1.2 Objective: what do we want to achieve?
1.3 Intent: what do we want operators to do?
1.4 Anti-trust/competition law considerations
2 An overview of the levels of information sharing
2.1 What are the levels of sharing?
2.2 What is their purpose?
2.3 How do they work?
3 Immediate incident notification and interim update
3.1 What is it?
3.2 What should it contain?
3.3 When should it be used?
3.4 Who should receive it?
3.5 How should it be used?
3.6 How should it be verified?
3.7 Where is the template?
3.8 Where are the examples?
4 Lessons learned from an incident investigation
4.1 What is it?
4.2 What should it contain?
4.3 When should it be used?
4.4 Who should receive it?
4.5 How should it be used?
4.6 How should it be verified?
4.7 Where is the template?
4.8 Where are the examples?
5 Lessons learned from a review of incident trends
5.1 What is it?
5.2 What should it contain?
5.3 When should it be used?
5.4 Who should receive it?
5.5 How should it be used?
5.6 How should it be verified?
5.7 Where is the template?
5.8 Where are the examples?
Appendix A1 Template of immediate incident notification and interim update
Appendix A2 Examples of immediate incident notification and interim update
Appendix B1 Template of lessons learned from an incident investigation
Appendix B2 Examples of lessons learned from an incident investigation
Appendix C1 Template of lessons learned from a review of incident trends
Appendix C2 Examples of lessons learned from a review of incident trends