Making incident learning reviews more effective
Across the industry, incident learning reviews (ILRs) often lack effectiveness and consistency. There’s a need to improve processes, support ILR Chairs, and enhance learning culture.
Performance teams often hold an ILR after a significant performance-impacting event. However, triggers and approaches to ILRs vary between performance teams.
This negatively affects the ability of ILRs to reduce the likelihood and consequences of disruptions.
Our research has given performance teams and ILR Chairs the resources they need to hold effective ILR meetings. It’s also given them the means to target the underlying causes of performance issues.
After developing a detailed understanding of existing ILR practices, including in adjacent industries, we developed good practice guidance in a structured and accessible way for performance teams to follow.
As part of this project, we also created and tested training materials to equip ILR Chairs with effective tools.
Improving ILRs will reduce the frequency and severity of events leading to disruptions. By using our guidance, ILR Chairs and participants will be more effective at finding mitigations and sharing learning outcomes.
Significant incidents are defined as those that cause over 1,000 delay minutes. There were 4,238 of these in 2023/24. As the industry adopts the outputs of this research, the level of disruption caused by this type of event should reduce.