The objective of this process is to learn about the system context associated with any special event within the organisation such that learning opportunities can be implemented.
This process covers any event within the organisation that is identified as a learning opportunity by an Accountable Manager. The event may have had either successful outcomes or had significant impact on service delivery, or the potential to have an impact, but without any explicit safety impact. The process may also be applied to any systemic issue identified within the operation including an adverse trend in safety performance that requires an investigation of the system context including covering actors external to the organisation.
This process is triggered by a request from an Accountable Manager.
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The following tools are examples of commercial products that support the implementation of this process.
The following material is publicly available and provides generic guidance to this process.