How to learn from the past

Today, quite by accident, I came across a paper published by the Institution of Civil Engineers in 2006, "The importance of learning from past experience" by Dr. Trevor Asher Kletz. It seems to me to be so relevant to the railway industry that I offer a summary of some of his advice below. The first one I've selected is so important I think it should be written into the rule book:

• "Never remove equipment or abandon procedures before it is discovered why they were introduced". This is so obvious and so often neglected that no further comment from me is necessary. 

• "Include a note on the reason why for every instruction, code and standard..." Although he doesn't say so, I'm sure he expects that the note should be part of the standard, not separated off in the dreaded "guidance notes". 

• For each process, there should be a folder of reports on past accidents, and that these should be compulsory reading for new recruits. 

Dr Kletz goes on to say that past major incidents should be included in the training of undergraduates and company employees. "The training," he says, "should start with accounts of accidents that demonstrate the need for codes, standards or instructions."
There is more, some of which is obvious, but the paper is worth reading in its own right. It can be found here:  Proceedings of the Institution of Civil Engineers – Civil Engineering, 2006, 161, No. CE6.