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
Source spread
Where this theme appears
Major project lessons learned has been flagged across 1 independent accountability source:
49 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (49)
POH-16 — Clarify whether HCRS and OCS assessment processes differ
Recommendation: 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 …
Gov response: Department for Business and Trade accepts this recommendation. DBT confirms that HCRS applies identical principles to the previous OCS scheme, ensuring no disadvantage to overturned conviction claimants. Case management and independent panel processes are in …
Accepted
MAI-155 — Obtain comprehensive accounts from commanders
Recommendation: 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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-128 — National systems to record lessons from exercises
Recommendation: 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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-127 — Robust debrief systems for multi-agency exercises
Recommendation: 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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-62 — LRF oversight of lessons from exercises and incidents
Recommendation: 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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-26 — Review international practice on medics with firearms officers
Recommendation: 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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-18 — Address BTP systemic failings from Volume 1
Recommendation: BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
5 — Require proper cell sharing risk assessments
Recommendation: 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 …
Gov response: A new staffing model delivers a healthier ratio of custodial staff per detained individual. The Home Office states that cell sharing risk assessments are covered under the new contractual arrangements.
Accepted in Part
FLIX-209 (iii) — Extend steam boiler modification regulations to hazardous material pressure systems
Recommendation: 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 …
Unknown
FLIX-209 (ii) — Inspect and test modified hazardous pressure systems by competent persons
Recommendation: 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 …
Unknown
FLIX-209 (i) — Ensure plant modifications meet original design, construction, testing standards
Recommendation: That any modifications should be designed, constructed, tested and maintained to the same standards as the original plant.
Unknown
SHI-10 — Uniform policy for obtaining technical advice
Recommendation: 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 …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
SHI-7 — Independent validation of hospital construction
Recommendation: 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 …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
In progress
SHI-6 — Information on common construction errors
Recommendation: 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 …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
In progress
SHI-5 — Streamlining NHS construction quality procedures
Recommendation: 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 …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025 (GIQ S6W-40544): NHS Scotland Assure has implemented a Key Stage Assurance Review (KSAR) process; specifications of …
Accepted
In progress
BAHA-46 — Lessons Learned Process
Recommendation: 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 …
Gov response: The Secretary of State for Defence accepted this recommendation in principle. Statement to Parliament, 8 September 2011: 'I am accepting in principle all of [Sir William's] recommendations with one reservation.'
Accepted
FENN-59 — Establish a managed safety programme to implement inquiry recommendations
Recommendation: 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.
Unknown
HIDD-46 — Fully implement Automatic Train Protection within five years, prioritising busy lines
Recommendation: 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 …
Unknown
HIDD-41 — Utilise on-train data recorder information for systematic safety monitoring procedures
Recommendation: BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Unknown
HIDD-36 — Continue implementing Total Quality Management Initiative and BS5750 quality systems
Recommendation: BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Unknown
FLIX-224 — Urgently investigate crack propagation and corrosion protection for clad steel vessels
Recommendation: 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.
Unknown
FLIX-223 — Review regulations for licensing and storage of highly flammable liquids
Recommendation: 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.
Unknown
FLIX-221 — Devise scheme for HSE to advise planning authorities on plant safety
Recommendation: 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.
Unknown
FLIX-216 — Install fire and explosion-proof recording devices for vital plant information
Recommendation: 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 …
Unknown
FLIX-214 — Inform industry about rapid creep cavitation fractures in stainless steel
Recommendation: 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 …
Unknown
FLIX-213 — Alert industry to risks of zinc-coated components in chemical plants
Recommendation: 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.
Unknown
FLIX-212 — Alert industry to nitrate stress corrosion risk from contaminated cooling water
Recommendation: 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 …
Unknown
CR18 — MAIB publication of implementation measures
Recommendation: 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 …
Response Pending
ETI-19 — Collaborative Delivery
Recommendation: 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 …
Gov response: The Inquiry Report describes some of the damaging behaviours adopted during project delivery by various parties. The advantage of co-locating representatives having an interest in project completion is understood and indeed was successfully adopted on …
Accepted
No update 2+ yrs
ETI-18 — Effective Communication and Reporting
Recommendation: 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.
Gov response: While this Recommendation is for third parties who may undertake a readiness review or audit of a publicly funded project in future, it is recommended that the Council agrees to support any such review or …
Accepted
No update 2+ yrs
F126 — Preserving corporate memory
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
44 — Establish framework for future investigations
Recommendation: 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 …
Gov response: 69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously …
Accepted
37 — Protocol for organisational change transitions
Recommendation: 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 …
Gov response: 100. We accept this recommendation. We agree that these are important concepts, and indeed a number of protocols were drawn up and widely communicated in managing changes to the health system in 2012. The Department …
Accepted
BAHA-20 — Doctrine Usability Review
Recommendation: 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.
Gov response: The Secretary of State for Defence accepted this recommendation in principle. Statement to Parliament, 8 September 2011: 'I am accepting in principle all of [Sir William's] recommendations with one reservation.'
Accepted
FENN-58 — Provide separate funds for scientific adviser's research and development
Recommendation: The scientific adviser of London Underground shall be provided with separate funds for research and development.
Unknown
LADB-6 — Improve Railtrack procedures for implementing and monitoring accepted recommendations with clear accountability
Recommendation: 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 …
Unknown
LADB-5 — Require holistic safety and risk assessment for all track or signalling changes
Recommendation: 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 …
Unknown
CLAR-2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: 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 …
Unknown
CLAR-1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: 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 …
Unknown
CLAR-13.53.2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: 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 …
Unknown
CLAR-13.53.1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: 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 …
Unknown
HIDD-54 — Complete research programme into structural integrity of rolling stock by April 1991
Recommendation: 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.
Unknown
HIDD-43 — Prioritise installation of driver-signalman radio communication on all traction units
Recommendation: 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 …
Unknown
HIDD-40 — Prioritise introduction of on-train data recorders for incident investigation assistance
Recommendation: BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Unknown
P2-58 — Reconsider LGA Guide paragraph 79.11 advice
Recommendation: That the advice contained in paragraph 79.11 of the LGA Guide be reconsidered. (113.83)
Gov response: The government accepts this recommendation. The advice contained in paragraph 79.11 of the LGA Guide was redacted in 2021. The Home Office intends to publish new guidance on the issues covered in paragraph 79.11 in …
Accepted
P2-57 — Reconsider Phase 1 recommendations in light of Phase 2
Recommendation: 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)
Gov response: The government accepts this recommendation. We addressed these recommendations in the response to the Emergency Evacuation Information Sharing Plus (EEIS+) consultation published on 2 December 2024.
Accepted
In progress
P2-9 — Include academics on statutory guidance advisory bodies
Recommendation: 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 …
Gov response: The government accepts this recommendation. We agree that a diverse range of representatives, including those from academic and professional communities, should be included in membership of bodies advising on changes to statutory guidance. The Building …
Accepted
In progress
P2-6 — Add legal requirements warning to statutory guidance
Recommendation: 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)
Gov response: The government accepts this recommendation. We will address this through the response to recommendation 5.
Accepted
In progress
R2 — HMP Maghaberry lessons learned
Recommendation: 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 …
Gov response: Secretary of State Owen Paterson stated on 14 September 2010 that he would discuss all three recommendations with Justice Minister David Ford, as prisons had become a devolved matter. Some operational lessons from HMP Maze …
Accepted