Critical Steps in Learning From Incidents

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

Drupsteen, L.
Groeneweg, J.
Zwetsloot, G.I.J.M.

2013

Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.

BSS - Behavioural and Societal Sciences
Organisation
Healthy Living
Work and Employment
Organisational learning
Incident
Survey
Learning potential
Case studies
SHB - Safe & Healthy Business

http://resolver.tudelft.nl/uuid:60b1004f-35d2-4da4-982e-e2e989ccbfd3

473964

International Journal of Occupational Safety and Ergonomics (JOSE), 19 (19), 63-77

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