Learning from Incidents demo
Describe the job in plain words and past near misses gather around it, with each closed action read against the procedure in force today. 1:21
What the demo shows
Finds past incidents like this job or change and shows what was learned, with sources.
A planner describes a job. Agents read the words, search the reports, follow each action to today's procedure, and show whether the hazard came back. The planner changes the plan and the shift supervisor signs. The fix then lands in a new revision that a second person signs and an agent reads back. Agents never say a job is safe.
Transcript
- Learning from Incidents shows planners and safety teams what happened last time.
- Reading 28,600 reports would take 9,533 hours, so agents do it.
- On the nearness map, two near misses land close.
- Same drum. 2017, a plug drain, rod under pressure, sprayed sour water.
- Did we learn? A 2020 rewrite lost the fix.
- In 2021, it came back with no action raised.
- Harleen adds a whole point.
- If flow stops, stop.
- Moses, the shift supervisor, opens both reports and the step, then signs.
- 373 closed actions are confirmed undone.
- 1,247 are still being checked.
- Two people back every fix.
- Oxana restores the step and Fergus signs.
- Built on Botminds: agents, data, screens, and governance on one platform.
Transcribed from the film’s narration. Captions are on the player.