Major project lessons learned
Repeated failure to effectively apply lessons learned from past major projects, leading to recurring mistakes in cost and schedule management.
49 items
1 source
16 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
86match
MAI-62 - LRF oversight of lessons from exercises and incidents
Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those events.
Matched on
terms: learned, lesson, major
Inquiry recommendation
74match
MAI-128 - National systems to record lessons from exercises
The Ministry of Housing, Communities and Local Government should ensure that there exist robust national and local systems to identify and record the lessons learned from all multi-agency exercises and ensure that change is implemented as a result, where change is indicated.
Matched on
terms: learned, lesson
Inquiry recommendation
74match
BAHA-46 - Lessons Learned Process
The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and into the pre-deployment training cycle.
Matched on
terms: learned, lesson
Inquiry recommendation
72match
SHI-6 - Information on common construction errors
It is important that common project errors are not repeated. One helpful step is to ensure health boards undertaking projects have information about such common errors, and that this information is clearly communicated to them. This would ensure that health boards are aware of such errors and thereby better equipped to avoid them. The information should be updated...
Matched on
terms: learned, lesson, project
Inquiry recommendation
65match
MAI-127 - Robust debrief systems for multi-agency exercises
The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems and sufficient resources to make sure that the debrief process following multi-agency exercises is effective to capture the lessons that need to be learned.
Matched on
terms: learned, lesson
Inquiry recommendation
65match
R2 - HMP Maghaberry lessons learned
Many of the problems of HMP Maze in 1997 arose from the fact that by then it was the sole prison in Northern Ireland holding the most dangerous terrorist prisoners. We are aware that HMP Maghaberry is currently the sole maximum security prison in Northern Ireland. We recommend that the SOSNI and those with recently devolved authority should...
Matched on
terms: learned, lesson
Inquiry recommendation
53match
MAI-155 - Obtain comprehensive accounts from commanders
The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should take steps to ensure that all emergency services understand the importance of promptly obtaining comprehensive accounts from commanders as part of the debrief process following a Major Incident.
Matched on
terms: major
Inquiry recommendation
48match
SHI-7 - Independent validation of hospital construction
It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility that the facility's specialised ventilation systems have been independently validated by an Authorising Engineer as fit for purpose and capable of achieving the operating performance originally specified. I accordingly recommend that, whatever the method adopted for...
Matched on
terms: project
Inquiry recommendation
48match
SHI-5 - Streamlining NHS construction quality procedures
A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment Process ("NDAP"). There is also a Sustainable Design and Construction Procedure ("SDAC"). In addition, there is the NHS Scotland Assure Key Stage Assurance Review (KSAR) procedure. These can be time-consuming and demanding to complete. There is...
Matched on
terms: project
Inquiry recommendation
45match
MAI-18 - Address BTP systemic failings from Volume 1
BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
Matched on
classifier match
Inquiry recommendation
44match
SHI-10 - Uniform policy for obtaining technical advice
This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it is not clear from the available evidence that any such changes have taken place more widely within the NHS. I accordingly recommend that a uniform policy or procedure...
Matched on
terms: project
Inquiry recommendation
43match
ETI-18 - Effective Communication and Reporting
There should be effective communication and reporting at all stages of the project, including accurate progress reports to councillors and stakeholders, with clear escalation procedures for issues that may affect cost, programme or scope.
Matched on
terms: project
Inquiry recommendation
41match
POH-16 - Clarify whether HCRS and OCS assessment processes differ
The Department shall make a public announcement in which (a) it clarifies whether there will be any differences in the process for assessing financial redress, between the merged HCRS and OCS, and the process currently operating in OCS and if so, (b) it explains what those differences in the process will be.
Matched on
classifier match
Inquiry recommendation
41match
MAI-26 - Review international practice on medics with firearms officers
Counter Terrorism Policing Headquarters should review the experience of other jurisdictions that embed medics with police firearms officers, such as Recherche, Assistance, Intervention, Dissuasion (RAID) in France, to understand how their systems operate and whether they ought to be replicated in the UK or some further learning taken from them.
Matched on
classifier match
Inquiry recommendation
40match
5 - Require proper cell sharing risk assessments
The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least every 14 days) or following any relevant change in circumstances. In the event that an immigration removal centre...
Matched on
classifier match
Inquiry recommendation
39match
ETI-19 - Collaborative Delivery
At all stages of the project there should be a collaborative approach to delivering it, including co-location of representatives from each organisation relevant to the particular stage, enabling issues to be addressed and resolved at the earliest opportunity, minimising risk of dispute escalation with associated delays and expense.
Matched on
terms: project
Inquiry recommendation
36match
FLIX-209 (iii) - Extend steam boiler modification regulations to hazardous material pressure systems
That existing regulations relating to modifications of steam boilers which do not apply to pressure systems containing hazardous materials should be extended so as to apply to such systems. In framing such regulations consideration will no doubt be given to the question whether the inherent nature of the material requires greater control than applies in the case of...
Matched on
classifier match
Inquiry recommendation
32match
FLIX-209 (ii) - Inspect and test modified hazardous pressure systems by competent persons
That all pressure systems containing hazardous materials should be subject to inspection and test by a person recognised by the appropriate authority as competent after any significant modification has been carried out and before the system is again brought into use.
Matched on
classifier match
Inquiry recommendation
32match
FLIX-209 (i) - Ensure plant modifications meet original design, construction, testing standards
That any modifications should be designed, constructed, tested and maintained to the same standards as the original plant.
Matched on
classifier match
Inquiry recommendation
31match
HIDD-36 - Continue implementing Total Quality Management Initiative and BS5750 quality systems
BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Matched on
classifier match
Inquiry recommendation
31match
FLIX-212 - Alert industry to nitrate stress corrosion risk from contaminated cooling water
The cracked Reactor R2525 initiated the sequence of events which led to disaster. Examination of the crack by expert metallurgists showed that the crack had been caused by nitrate stress corrosion. This corrosion was created because nitrate treated cooling water had been used in the past to dilute some of the process liquids which contaminated the cooling water....
Matched on
classifier match
Inquiry recommendation
31match
44 - Establish framework for future investigations
This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were overcome, but the need to do this from scratch each time an investigation of this format is set...
Matched on
classifier match
Inquiry recommendation
27match
FENN-59 - Establish a managed safety programme to implement inquiry recommendations
London Underground must establish a managed safety programme under the control of the Director and Company Secretary initially to implement the recommendations in this Report. In time it should be extended to cover other activities.
Matched on
classifier match
Inquiry recommendation
27match
HIDD-46 - Fully implement Automatic Train Protection within five years, prioritising busy lines
The Court welcomes BR's commitment to introduce Automatic Train Protection on a large percentage of its network, but is concerned at the timetable proposed. After the specific type of ATP system has been selected, ATP shall be fully implemented within 5 years, with a high priority given to densely trafficked lines.
Matched on
classifier match
Inquiry recommendation
27match
HIDD-41 - Utilise on-train data recorder information for systematic safety monitoring procedures
BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Matched on
classifier match
Inquiry recommendation
27match
FLIX-224 - Urgently investigate crack propagation and corrosion protection for clad steel vessels
The question of crack propagation and detection in internally clad mild steel vessels and their protection from corrosion on the outside should be investigated as a matter of urgency.
Matched on
classifier match
Inquiry recommendation
27match
FLIX-223 - Review regulations for licensing and storage of highly flammable liquids
We have pointed out in Paragraph 194 (c) above that the present situation regarding the licensing and storage of highly flammable liquids is unsatisfactory. We recommend review of the existing regulations.
Matched on
classifier match
Inquiry recommendation
27match
FLIX-221 - Devise scheme for HSE to advise planning authorities on plant safety
A scheme for co-ordination between the planning authorities and the Health and Safety Executive should be devised so that the planning authorities may be advised on the safety problems involved in any proposed plant before planning permission is granted.
Matched on
classifier match
Inquiry recommendation
27match
FLIX-216 - Install fire and explosion-proof recording devices for vital plant information
It is recommended that consideration be given to installing devices or systems for recording vital plant information in a form which would survive the effects of fire or explosion. An example of such a device is the “black-box” used in aircraft.
Matched on
classifier match
Inquiry recommendation
27match
FLIX-214 - Inform industry about rapid creep cavitation fractures in stainless steel
Creep cavitation fractures in stainless steel have been known for some time but previously it had not been generally known that these could, under appropriate conditions of stress and temperature be produced in a relatively short time. Such a fracture can be produced in a matter of minutes by a small fierce fire. This phenomenon was demonstrated during...
Matched on
classifier match
Inquiry recommendation
27match
FLIX-213 - Alert industry to risks of zinc-coated components in chemical plants
Since many chemical plants contain zinc coated components, eg galvanised wire and walkways, it is important that the attention of industry should be drawn to these matters.
Matched on
classifier match
Inquiry recommendation
27match
CR18 - MAIB publication of implementation measures
The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom a recommendation is addressed, or an explanation for not taking implementing measures, unless there are strong reasons not to do so. If needs be, the 2012 Regulations should...
Matched on
classifier match
Inquiry recommendation
27match
F126 - Preserving corporate memory
The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as new clinical commissioning groups are formed, and guidance for commissioners on what they should expect to see in...
Matched on
classifier match
Inquiry recommendation
27match
37 - Protocol for organisational change transitions
Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This must include systems to secure retention of both electronic and paper documents against future need, as well as...
Matched on
classifier match
Inquiry recommendation
27match
BAHA-20 - Doctrine Usability Review
The MoD should ensure that Development Concepts and Doctrine Centre (DCDC) reviews whether its protocols for layout and pagination of joint doctrine really serve the end user.
Matched on
classifier match
Inquiry recommendation
27match
LADB-6 - Improve Railtrack procedures for implementing and monitoring accepted recommendations with clear accountability
Railtrack procedures, and the actions of management to enforce them, should be directed to ensuring that: (i) a recommendation which is accepted is implemented according to a defined timescale; (ii) the person to whom a recommendation is allocated for implementation is required to report periodically the action which has been taken, the state of progress and the reasons...
Matched on
classifier match
Inquiry recommendation
27match
LADB-5 - Require holistic safety and risk assessment for all track or signalling changes
Where a material change to track or signalling or both is proposed, there should be an express consideration of all relevant safety issues by an analysis of the material factors, if necessary by means of a risk assessment. This should be done on a holistic basis at the design concept stage and repeated at defined stages up to...
Matched on
classifier match
Inquiry recommendation
27match
P2-9 - Include academics on statutory guidance advisory bodies
That, as far as possible, membership of bodies advising on changes to the statutory guidance should include representatives of the academic community as well as those with practical experience of the industry (including fire engineers) chosen for their experience and skill and should extend beyond those who have served on similar bodies in the past. (113.14)
Matched on
classifier match
Inquiry recommendation
23match
FENN-58 - Provide separate funds for scientific adviser's research and development
The scientific adviser of London Underground shall be provided with separate funds for research and development.
Matched on
classifier match
Inquiry recommendation
23match
CLAR-2 - Secretary of State to direct formal investigation includes search and rescue operation
Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the Merchant Shipping (Formal Investigations) Rules 1985, as amended.
Matched on
classifier match
Inquiry recommendation
23match
CLAR-1 - Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the loss of life and the injuries suffered by those who survived.
Matched on
classifier match
Inquiry recommendation
23match
CLAR-13.53.2 - Secretary of State to direct formal investigation includes search and rescue operation
Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the Merchant Shipping (Formal Investigations) Rules 1985, as amended.
Matched on
classifier match
Inquiry recommendation
23match
CLAR-13.53.1 - Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the loss of life and the injuries suffered by those who survived.
Matched on
classifier match
Inquiry recommendation
23match
HIDD-54 - Complete research programme into structural integrity of rolling stock by April 1991
BR shall carry out its stated programme of research into the structural integrity of its rolling stock within its planned timescale of completion by April 1991.
Matched on
classifier match
Inquiry recommendation
23match
HIDD-43 - Prioritise installation of driver-signalman radio communication on all traction units
BR shall implement as a priority its programme to install a system of radio communication between driver and signalman on all traction units. The introduction of this system shall be in addition to signal-post telephones and not automatically entail their removal.
Matched on
classifier match
Inquiry recommendation
23match
HIDD-40 - Prioritise introduction of on-train data recorders for incident investigation assistance
BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Matched on
classifier match
Inquiry recommendation
23match
P2-58 - Reconsider LGA Guide paragraph 79.11 advice
That the advice contained in paragraph 79.11 of the LGA Guide be reconsidered. (113.83)
Matched on
classifier match
Inquiry recommendation
23match
P2-57 - Reconsider Phase 1 recommendations in light of Phase 2
That further consideration be given to the recommendations made in the Phase 1 report in the light of our findings in this report. (113.82)
Matched on
classifier match
Inquiry recommendation
23match
P2-6 - Add legal requirements warning to statutory guidance
That a revised version of the guidance contain a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them. (113.12)
Matched on
classifier match