AU2017279810A2

AU2017279810A2 - Fatality learning system and method

Info

Publication number: AU2017279810A2
Application number: AU2017279810A
Authority: AU
Inventors: Stephen Mark Wood
Original assignee: Forwood Entpr Pty Ltd
Current assignee: Forwood Enterprises Pty Ltd
Priority date: 2016-12-23
Filing date: 2017-12-22
Publication date: 2023-02-23
Also published as: WO2018112505A1; AU2023200379A1; ZA201904467B; AU2017279810A1; CA3085808A1

Abstract

A fatality learning system and method, the system comprising; a centrally located critical risk database comprising questions classified in a taxonomic structure; a lessons learned database comprising information taken from fatality learnings and incident reports; and checklists comprising questions selected from the critical risk database, wherein a plurality of checklists are directed to an activity, the different checklists being configured to suit different roles required to perform the activity, wherein the critical risk database is arranged to be updated based on information added to the lessons learned database, and wherein the checklists are updated with the updated critical risk database content, the method comprising the following steps: a. Following a fatality or a potentially fatal incident during a critical risk activity, an incident report is created comprising a detailed description of the incident, the incident report is added to the lessons learned database. b. The incident report is used to identify the classifications and questions in the critical risk database relevant to the incident. c. Amendments to the critical risk database in the form of amendments to questions or new questions are proposed based on the content of the incident report. d. The classifications identified and proposed amendments to the questions are reviewed and further amendments made where required. e. The amendments are uploaded to the critical risk database, making updated information available to the checklists instantaneously, the revised checklists being available to users in the field instantaneously. 1/3 20 Loiem 4sndolor Vestibulum nec Dowectrislique ml Phstus lbero nisi sit amet contectt tenipus mauris, non lomni sed Interdum lobortisviAmsagittis 50 adipiscing elt.Njla eugat eratVivamus viu neclme.) taejfaucbus Id puu t lectus eulsmod umaviAe Fumce aplnnunc t~d~nunc. In 22 tempus elemnentumn mauris femwrmn ulbces In erat Wmcorp~f-Q;jo Id quis vitae maurs. sollicitudin.Donecat tempus, posuere paagaia Elarnqtseratut dul toter ex.Nu~a bnaun Preentpretium 52 fttngllla solltcitudin. facll. onec Vesibilum ante diam ante, eu Pellentesque gravida tpmipaliquarn lpsum primis In tulstlw mretus Isendrerit lacus, ut sapien.Suspendisse laucbvaonjcsIuw-- eu-ada quis Consequat iamn fals netus et etultrkcesposuete Matilsviustate aliquetted. Sed neque laclla actor. cubilla Cura Dolt ternUt lects condirnentumn Pellentesquesuscipit hendreit molestle dapw uis feuglat magna6 nec ord set, at tongue neque sit arnet placerat ex gravida. ~-10 40 58 70 6 Figure1I

Description

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AUSTRALIA

PATENTSACT1990

COMPLETE SPECIFICATION

FOR AN INNOVATION PATENT (Original)

APPLICATION NO: LODGED: 22 December 2017

COMPLETE SPECIFICATION LODGED: ACCEPTED: PUBLISHED: RELATED ART:

NAME OF APPLICANT: Forwood Enterprises Pty Ltd

ACTUALINVENTOR: Stephen Mark Wood

ADDRESS FOR SERVICE: WRAYSPTYLTD Patent and Trade Mark Attorneys, of Level 7, 863 Hay St, Perth Western Australia, 6000, AUSTRALIA.

INVENTION TITLE: "FATALITY LEARNING SYSTEM AND METHOD" DETAILS OF ASSOCIATED PROVISIONAL APPLICATION NO'S:

Australian Provisional Patent Application Number 2016905377 filed on 23 December 2016

The following Statement is a full description of this invention including the best method of performing it known to me/us:

TITLE FATALITY LEARNING SYSTEM AND METHOD FIELD OF INVENTION

[0001] The present invention relates to a fatality learning system and method.

[0002] More particularly, the present invention relates to a fatality learning system and method for use in computer implemented global risk management systems.

BACKGROUNDART

[0003] Workplace safety is of the utmost importance in many industries, especially industries such as mining, oil and gas, manufacturing, power generation, aviation, aerospace and nuclear, due to the numerous opportunities for harm to be caused to personnel. Risk management techniques have been adapted to reduce instances of injury to workers, damage to equipment and loss of production time.

[0004] It is known in the art to manage risk in high risk environments by the use of checklists, which must be completed prior to an individual engaging in a high risk activity, to ensure all required steps have been taken to reduce the risk of injury or death.

[0005] Risk is typically managed by supervisors and operators in each facility, completing checklists in accordance with company procedures.

[0006] In the event of a fatality, or the recognition of a potential fatal incident, it is known that an incident record may be created, providing details of the incident.

[0007] Common problems with managing risk on a global scale include the ability to learn from fatalities and significant incidents, to capture, share and embed the lessons learned and to reduce risk by implementing improvements. Incident records may be inconsistent, with information provided therein being difficult to standardise and share with other locations in a way that ensures transfer of knowledge.

[0008] Further inconsistencies exist due to the often global nature of businesses, with facilities across numerous continents and involving different languages, and these inconsistencies can pose severe difficulties in both reporting incidents and effecting sustainable change.

[0009] The difficulty of capturing the incident information and implementing change often results is similar fatalities and potentially fatal incidents occurring, which may have been preventable.

[0010] It would be desirable to provide a fatality learning system and method that would assist in at least partially overcoming these problems.

SUMMARY OF THE INVENTION

[0011] According to the present disclosure, a fatality learning system and method is provided for access by users in the field via a device, the system comprising: a centrally located critical risk database comprising questions classified in a taxonomic structure; a lessons learned database comprising information taken from fatality learnings and incident reports; and checklists comprising questions selected from the critical risk database, wherein a plurality of checklists are directed to a critical risk activity, the different checklists being configured to be suit different roles required to perform the critical risk activity, wherein the critical risk database is arranged to be updated based on information added to the lessons learned database, and wherein the checklists are updated with the updated critical risk database content, the method comprising the following steps:

a. following a fatal, or a potentially fatal, incident during a critical risk activity, an incident report is created comprising a detailed description of the incident, and the incident report is added to the lessons learned database; b. the incident report is used to identify classifications and questions in the critical risk database relevant to the incident; c. amendments to the critical risk database in the form of amendments to questions or new questions are proposed based on content of the incident report; d. the classifications identified and the proposed amendments to the questions are reviewed and further amendments are made where required; and e. the amendments are uploaded to the critical risk database, making updated information available to the checklists instantaneously, whereby revised checklists subsequently are available to users in the field instantaneously.

[0012] In an embodiment, the different roles to which the different checklists are adapted comprise manager, supervisor, and operator roles, so that checklists are available reflecting the questions relevant to manager, supervisor, and operator aspects of performing a critical risk activity.

[0013] In an embodiment, information contained in the incident report is linked to relevant questions in the critical risk database, so that the information is visible to a user when the user views a checklist comprising a question linked to an incident report.

[0014] In an embodiment, the checklist displays a symbol where a question is linked to an incident report.

[0015] In an embodiment, upon being presented with an incident report, the user must view the incident report before being able to review subsequent questions on the checklist.

[0016] In an embodiment, the questions relevant to manager aspects are directed to activities within a manager's responsibility, wherein the questions relevant to supervisor aspects are directed to activities within a supervisor's responsibility. The questions relevant to operator aspects are directed to activities within an operator's responsibility.

[0017] In an embodiment, a question may be provided on the checklists suited to more than one role, so that the question is presented to end users performing different roles.

[0018] In an embodiment, the questions relevant to supervisor aspects are identical to the questions relevant to operator aspects, so that the supervisor checklist comprises identical questions to the operator checklist.

[0019] In an embodiment, the supervisor checklist is used as a review of the operator checklist, so that a user of the supervisor checklist may determine appropriate critical risk activities suitable for review.

[0020] In an embodiment, the structure of the questions in the critical risk database includes subcategories and cross-references to facilitate the linking of questions to activities.

[0021] In an embodiment, at step b. the incident report is scanned using keywords to facilitate the classification of the report within the database, and to assist with identifying relevant questions.

[0022] In an embodiment, checklists and questions are available in multiple languages to suit native languages of different users.

[0023] In an embodiment, checklists and questions are displayed alongside images to aid the understanding of a user.

[0024] In an embodiment, an incident report comprises a feedback section, configured to be completed by a user with information to assist with classification of the incident report, or with information to assist with amendments or additions to questions in the critical risk database to prevent similar incidents in future.

[0025] In an embodiment, the lessons learned database is configured to have amendments or additions proposed by users directly, without the need for an incident report.

[0026] In an embodiment, the user's response time is logged and assessed to identify responses which may not be accurate.

[0027] In an embodiment, the incident report includes relevant information about the operator involved in the critical risk activity being performed at the time of the incident.

[0028] In an embodiment, the incident report is created in a selected format, wherein the selected format is arranged to be classified according to the structure of the critical risk database.

BRIEF DESCRIPTION OF DRAWINGS

[0029] The present invention will now be described, by way of example, with reference to the accompanying drawings, in which:

Figure 1 identifies the key elements and illustrates the process from occurrence of an incident, creation of an incident report, submission of the incident report to the lessons learned database, amendment of the critical risk database and amendment of checklist questions.

Figure 2 illustrates the different roles of end user, and how the different critical control checklists are provided based on different user levels.

Figure 3 illustrates the structure of the questions according to the different roles of end user, according to a preferred embodiment of the present invention.

Figure 4 illustrates the structure of the questions according to the different roles of end user, according to another preferred embodiment of the present invention.

DETAILED DESCRIPTION OF THE PREFFERRED EMBODIMENT

[0030] As shown in the Figures, there is provided a fatality learning system and method, the system comprising; a centrally located critical risk database 20 comprising questions 22 classified in a taxonomic structure; a lessons learned database 30 comprising information taken from fatality learnings and incident reports 40; and checklists 50 comprising questions 52 selected from the critical risk database 20, wherein a plurality of checklists 50 are directed to an activity 60, the different checklists 50 being configured to suit different roles required to perform the activity 60, wherein the critical risk database 20 is arranged to be updated based on information added to the lessons learned database 30, and wherein the checklists 50 are updated with the updated critical risk database content, the method comprising the following steps:

a. Following a fatality or a potentially fatal incident during a critical risk activity, an incident report is created comprising a detailed description of the incident, the incident report is added to the lessons learned database.

b. The incident report is used to identify the classifications and questions in the critical risk database relevant to the incident.

c. Amendments to the critical risk database in the form of amendments to questions or new questions are proposed based on the content of the incident report.

d. The classifications identified and proposed amendments to the questions are reviewed and further amendments made where required.

e. The amendments are uploaded to the critical risk database, making updated information available to the checklists instantaneously, the revised checklists being available to users in the field instantaneously.

[0031] A critical control checklist 50 is presented to a user before completing a critical risk activity 60.

[0032] For clarity and ease of description, the questions are identified as 22, 32 and 52, to distinguish them at different stages within the process, but otherwise are essentially the same. As stored in the central critical risk database 20 the questions are identified as 22, as presented to a user in a critical control checklist 50 the questions are identified as 52, and as stored in the lessons learned database 30 as amended questions they are identified as 32.

[0033] Similarly, the lessons learned database 30 and the critical risk database 20 are defined as two separate databases for ease of description. This is done to denote the state of the content of each database, being proposed amended questions 32 in the lessons learned database 30, and approved and classified questions 22 in the critical risk database 20.

[0034] The taxonomy of the critical risk database 20 is such that the questions 22 are classified at a first level by the nature or cause of a potentially fatal injury (the risk), for example "Fall from Height" or "Lifting Operations".

[0035] The questions 22 may be classified at a second level into sub-categories relevant to the first level, for example within the first level category of "Fall from height" may be a number of sub-categories defining factors relevant to the critical controls that can prevent a Fall from Height, such as "Scaffolding" or "Fall Protection System".

[0036] In the preferred embodiment of the present invention, an end user may select and complete the critical control checklist 50 relevant to the activity 60 about to be performed from the critical risk database 20, wherein the critical control checklist 50 will comprise questions 52 particular to the activity 60.

[0037] In an alternative embodiment of the present invention, sets of questions 52 in a critical control checklist 50 may be tailored to an activity 60, useful particularly when working in non-standard conditions, where more than one category may be relevant to the task about to be performed, or where some questions may be redundant to a particular task.

[0038] The critical control checklists 50 correspond to activities 60. These activities 60 require the appropriate critical control checklist 50, which may be identical across a number of different locations worldwide, and in a number of different languages, to be completed before proceeding with the activity 60. For example, the activity of repairing a conveyor belt may require the same critical control checklists 50 wherever it may be carried out.

[0039] As shown in Figure 2, the preferred embodiment of the present invention comprises three levels of critical control checklist 50, described henceforth as 53, 55 and 57, adapted for different levels of end user. The first level critical control checklist 53 may be adapted for completion by management 54, and comprises questions 52 relevant to activities within the scope of work of site managers and superintendents 54, an example of a question 52 on a first level checklist 53 may be "Are appropriate permits in place for the operation?", or "Has the correct atmospheric monitoring equipment been supplied for this task?".

[0040] As shown in Figure 3, the second level critical control checklist 55 is adapted for completion by the supervisor 56, and comprises questions 52 relevant to the scope of work of the supervisor 56, an example of a question 52 on a second level checklist 55 may be "Has the confined space entry permit been correctly executed in the field?", or "Has the required equipment been calibrated and certified within the recommended timescale?"

[0041] In an alternative embodiment of the present invention, shown in Figure 4, the second level critical control checklist 55, to be completed by the supervisor 56, comprises identical questions 52 to those provided on the third level critical control checklist 57, completed by the operator 58.

[0042] In this particular embodiment, the second level critical control checklist is not required to be completed before carrying out the activity 60, but the checklist serves as a supervisor 56 review, to check that an operator 58 has been completing the third level critical control checklist 57 correctly, and provides the supervisor 56 freedom to decide which checklists to review, given the supervisor's 56 knowledge of the activities 60 to be performed and the particular operators 58 assigned to the activities 60.

[0043] The third level critical control checklist 57 is adapted for completion by the operator 58, and comprises questions 52 relevant to the scope of work of the operator 58, an example of a question 52 on a third level checklist 57 may be "Have you read and signed the confined space entry permit?", or "Are you aware of the gases that may be present in the confined space and the potential health effects of exposure to these gases?"

[0044] In an alternative embodiment of the present invention, a single level of critical control checklist 50 may be provided to the end user.

[0045] In alternative embodiments of the present invention, different numbers of levels of critical control checklists 50 may be provided and may be adapted for completion by different types of end user.

[0046] The end users may complete the critical control checklists 50 via a computer terminal, or similarly connected device such as a tablet or smart mobile phone.

[0047] Alternatively, the end uses may complete critical control checklists 50 in paper format.

[0048] The response time and history of the end user's response may be logged and assessed to identify responses which may not be accurate.

[0049] For example, where the responses are unusually quick, this may indicate that the end user has not read and understood the question before answering, or for example where the end user provides one answer, but then changes to an answer suitable for the work to proceed, which may indicate that the answer was provided only to allow the work to proceed, even if it did not reflect the situation at the time.

[0050] The fatality learning system and method 10 may comprise a facility to raise issues, whereby the end user can HALT the activity, describe the issue, and raise a support request 70.

[0051] The support request 70 may then be made available to any relevant person or people, for example the manager 54, the supervisor 56 and a maintenance technician.

[0052] The support request 70 may then be assigned and prioritised accordingly.

[0053] A support request 70 may refer to activities which are not specific to maintenance, for example issuing of a lanyard of good repair, or any action to improve safety of the activity 60.

[0054] The fatality learning system and method 10 may comprise a HELP function, whereby an end user may activate the HELP function in an emergency, or if they find themselves in a situation where help is required.

[0055] The HELP function may signal to all end users on the site to provide assistance, alternatively the HELP function may be adjusted to signal users nearby for example.

[0056] The fatality learning system and method 10 may comprise function for end users to add to checklists 50, to customise the information and questions 22 according to their particular situation.

[0057] For example, an operator 58 and supervisor 56 may determine a preferred method of completing a particular activity 60, and may define additional questions 52 related to critical risk activities 60.

[0058] Customised checklists 50 may then be entered into the lessons learned database , and subsequently reviewed to provide further learnings and the content incorporated into the critical risk database 20.

[0059] In this example, the operator 58 and supervisor 56 may define and classify the additional questions 52, which are then submitted to the lessons learned database 30. The questions are submitted as proposed new questions 32 to the lessons learned database, where they are reviewed and once confirmed, provided to the critical risk database 20 as critical risk questions 22. Once stored in the critical risk database 20 the questions 22 become available to the critical control checklists 50 as questions 52 for the end user.

[0060] The end users may complete the critical control checklists 50 via a smart watch, or similarly connected device such as a wrist band, pendant or tracker.

[0061] The end users may complete the critical control checklists 50 via a voice recognition device, or similarly connected device such as remote headset or Amazon Echo.

[0062] The end users may complete the critical control checklists 50 via a visual device, or similarly connected device such as Google Glass or Microsoft Halo.

[0063] Alternatively, the end user may complete the critical control checklists 50 using a paper print out for example.

[0064] The end users may be assisted with the critical control checklists 50 using artificial intelligence, where the questions 52 are asked in a suitable manner using a chat bot for example.

[0065] Voice recognition may be incorporated to assist the end user with completing the critical control checklist 50.

[0066] The fatality learning system and method 10 operates globally with access points available for operators across every site in multiple languages.

[0067] In use, end users access the interface prior to commencing a critical risk activity , and a device or document displays the appropriate critical control checklist 50 for the activity 60. The questions 52 on the critical control checklist 50 comprise the best available information to prevent injury or death, in the form of a set of questions 52 to be answered before proceeding with the activity 60. Providing all the questions 52 are reviewed and sincerely answered in the affirmative, the risk of harm is reduced significantly.

[0068] In the event of a fatality or the recognition of a potential fatal incident while performing an activity 60 an incident report 40 is created.

[0069] The incident report 40 may be generated using any format, and may not necessarily be suited for use with the fatality learning system and method 10 described in the present invention.

[0070] The incident report 40 may be reviewed, in conjunction with the critical control checklist 50 presented to the user prior to performing the activity 60 during which the incident occurred, to determine the risk and control classification of the incident report 40 within the structure of the critical risk database 20.

[0071] The incident report 40 may further be scanned using a combination of keywords and closest match questions to determine the appropriate risk and control classification of the incident report 40 within the structure of the critical risk database 20.

[0072] The review and classification of the incident report 40 allows the specific question or questions 52 which were associated with the incident, and which were presented to an operator on the critical control checklist 50 to be identified.

[0073] If the questions 52 presented had not been reviewed by the operator, and as a result an incident had occurred, it may be that no amendments are required, although the incident report 40 may still be added to the critical risk database 20 and linked to the relevant questions 22. The addition of the incident report 40 notifies users of the incident, and provides a report to them for review.

[0074] If an incident report 40 is added to the critical risk database 20 and linked to the relevant questions 22 and 'stamping' a FATALITY symbol or STOP notification occurs, this can be sent out as an instant notification to any device prior to the operator, supervisor or manager using the critical control checklist.

[0075] Instant notifications, for example push notifications, can be used to inform the operator, supervisor or manager of any additions or changes to the critical risk database 20 or the lessons learned database 30. Examples of instant notifications include; new questions added, questions modified, fatality alerts, black spots, hot spots, changed conditions, critical risk alerts and critical control alerts.

[0076] Users who perform activities 60 on a regular basis may proactively review incident reports 40 and stored instant notifications from around the world relevant to these activities 60, thus gaining an insight into the causes of incidents during the performance of these activities 60.

[0077] Amendments are determined by reviewing the questions 52 provided to the operator in the critical control checklist 50 and the incident analysis report 40 to determine the cause or causes of the incident, and prevent the incident occurring again.

[0078] The amendments are added to the lessons learned database 30 in the form of amendments to questions 32, or new questions 32.

[0079] The original incident report 40 may also be added to the lessons learned database as supporting information, and may be linked to the amended questions 32.

[0080] The incident report 40 may further include relevant information about the operator 58 involved in the activity 60 being performed at the time of the incident.

[0081] Additional information may be added to the incident report 40, in the form of supporting information and the outcome of the incident, for example permanent injury of death.

[0082] Once all information particular to an incident has been added to the lessons learned database 30, including any amended or new questions 32 and the risk and control classification, the information is uploaded to the critical risk database 20.

[0083] At this point the amended or new questions 32 contained in the lessons learned database 30 are transferred to the critical risk database 20, updating the questions 22 contained therein, resulting in an improved set of questions 22 and related information in the critical risk database 20.

[0084] This may be done using the risk and control classifications provided following the review of the incident report 40.

[0085] Once the amended or new questions 32 are uploaded to the critical risk database , the resultant questions 22 become instantly available to all end users world-wide, in the form of questions 52 on critical control checklists 50, which are live-linked to the critical risk database 20.

[0086] The availability of the improved questions 52 results in a safer work environment by providing the lessons learned immediately to users worldwide.

[0087] The benefit of this method is that users are always applying the lessons learned from fatalities and potential fatal incidents in the field, at every level of the organisation (Manager, Supervisor and Operator), every day, before an activity 60 is performed.

[0088] In another embodiment of the present invention, where an incident has resulted in a fatality, the amended or new questions 32 may include a FATALITY symbol or STOP notification declaring specifically that a fatality has occurred, and it provides a description of the activity 60 being performed at the time.

[0089] A STOP notification is highlighted in the associated questions 52 provided to the user in the critical control checklist 50, and may require the user to read the fatality description, including the detailed information of the fatality, before commencing the activity.

[0090] The critical risk database 20 may comprise translations of questions 22 into a number of languages, so that critical control checklists 50 may be provided with questions 52 in a language native to, or understood by, the end user.

[0091] In another embodiment of the present invention, the critical control checklists 50 are provided with pictograms for each question that are aligned with the culture of the end user.

[0092] In another embodiment of the present invention, the critical control checklists 50 are provided with photographs or images for each question and aligned with the culture of the end user.

[0093] In another embodiment of the present invention, the incident report 40 is created in a selected format, wherein the format is arranged to be classified according to the structure of the critical risk database 20.

[0094] In this embodiment the incident report 40 further comprises sections to identify the failures causes, and to provide recommendations to prevent future failures.

[0095] The use of the incident report 40 in a selected format facilitates the risk and control classification and continuous improvement of the database, thus reducing the requirement for review and reducing the likelihood of errors by providing the information in a preferred format.

[0096] Throughout this specification, the terms management, supervisor and operator are used to describe roles, and checklists associated with roles. These terms are used purely to identify the different roles and checklists, and are in no way limiting the scope to users fitting such descriptions.

[0097] For example a manager 53, and manager level checklist 54 may be assigned to someone who is not necessarily considered a manager.

[0098] Similarly, operators 58 may encompass a variety of roles including maintenance technician, contractor and cleaner for example.

[0099] Modifications and variations as would be apparent to a skilled addressee are deemed to be within the scope of the present invention. That is, it will be appreciated by persons skilled in the art that numerous variations and/or modifications may be made to the invention as described in the specific embodiments without departing from the scope of the invention as broadly described. The present embodiments are, therefore, to be considered in all respects as illustrative and not restrictive.

[00100] Throughout this specification, unless the context requires otherwise, the terms "comprise", "comprising", "include", "including", "contain", "containing", "have", "having", and any variations thereof, are intended to be understood in an inclusive (i.e., non-exclusive) sense so as to imply the inclusion of a stated step, integer, feature, or element, or group of steps, integers, features, or elements, but not the exclusion of any other step, integer, feature, or element, or group of steps, integers, features, or elements.

[00101] Any reference to background art herein, including to any documents, is intended to facilitate an understanding of the present invention only and shall not be considered as an admission that such background art forms part of the prior art base, or that such background art is widely known or forms part of the common general knowledge in the relevant field in Australia or in any other country.

Claims

A fatality learning system and method for access by users in the field via a device, the system comprising: a centrally located critical risk database comprising questions classified in a taxonomic structure; a lessons learned database comprising information taken from fatality learnings and incident reports; and checklists comprising questions selected from the critical risk database, wherein a plurality of checklists are directed to a critical risk activity, the different checklists being configured to suit different roles required to perform the critical risk activity, wherein the critical risk database is arranged to be updated based on information added to the lessons learned database, and wherein the checklists are updated with the updated critical risk database content, the method comprising the following steps:

a. following a fatal, or a potentially fatal, incident during a critical risk activity, an incident report is created comprising a detailed description of the incident, and the incident report is added to the lessons learned database;

b. the incident report is used to identify classifications and questions in the critical risk database relevant to the incident;

c. amendments to the critical risk database in the form of amendments to questions or new questions are proposed based on the content of the incident report;

d. the classifications identified and proposed amendments to the questions are reviewed and further amendments are made where required; and

e. the amendments are uploaded to the critical risk database, making updated information available to the checklists instantaneously, whereby the revised checklists are available to users in the field instantaneously.
2. A fatality learning system and method according to claim 1, wherein the different checklists adapted to suit different roles comprise manager, supervisor, and operator checklists, so that checklists are provided reflecting the questions relevant to manager, supervisor, and operator aspects of performing a critical risk activity; and/or wherein checklist questions are displayed alongside images to aid user understanding.
3. A fatality learning system and method according to claim 1 or 2, wherein information contained in the incident report is linked to relevant questions in the critical risk database, so that the information is visible to a user when the user views a checklist comprising a question linked to an incident report.
4. A fatality learning system and method according to claim 3, wherein the checklist displays a symbol where a question is linked to an incident report, and/or wherein, upon being presented with an incident report, the user must view the incident report before being able to review subsequent questions on the checklist.
5. A fatality learning system and method according to any one of the preceding claims, wherein at step b. the incident report is scanned using keywords to facilitate the classification of the report within the database, and to assist with identifying relevant questions; and/or wherein the user's response time to completing a checklist is logged and assessed to identify responses which may not be accurate.