What are the bottlenecks in the learning from incidents process?
conference paper
The main purpose of our ongoing study is to develop knowledge on how to improve learning from incidents in organisations. In this phase of the study insight into the main bottlenecks is created. Many organizations investigate accidents and incidents to understand what happened, what caused it and why, and how to learn lessons from them to prevent re-occurrence. No matter how accurate the investigation and analysis are: further steps are necessary to prevent re-occurrence. By learning from incidents, re-occurrence of these incidents and the occurrence of similar events can be prevented and therefore safety performance can be improved. In an earlier phase of the study a model of the learning from incidents process, which is the process from reporting an incident to verifying the effectiveness of remedial measures, is developed. A survey was performed to locate where the main bottlenecks arose. In this paper the types of bottlenecks that hinder the learning from incidents process will be described.
Topics
TNO Identifier
516461
ISSN
03070492
ISBN
9781622767892
Source title
22nd Institution of Chemical Engineers Symposium on Hazards 2011: Process Safety and Environmental Protection, HAZARDS 2011, 11-14 April 2011, Liverpool, UK
Pages
94-98
Files
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