Improving organisational safety through better learning from incidents and accidents
doctoral thesis
The main objective of this dissertation is to contribute to better learning from safety related incidents and accidents in organisations. The dissertation provides a method to systematically study learning from incidents, by using a model of five phases that represent the actions necessary to successfully follow up on incidents and to learn from them. The model builds on existing theories from safety and organisational learning, that are now applied to learning from incidents. In addition, this dissertation explains causes for ineffective learning, and a set of indicators to assess the conditions that facilitate learning, is provided. Through creating and sustaining these conditions in which successful learning is likely to occur, the ability of an organisation to learn improves.Thus, this dissertation increases the understanding of learning from incidents by providing empirical findings on how organisations learn from incidents in practice, and on hindrances and successes in the current learning approaches.
TNO Identifier
520120
ISBN
978-87-91831-64-5
Publisher
Centre for Industiral Production ; TNO
Collation
116 p.
Place of publication
Copenhagen