Identifying the bottlenecks in learning from incidents: From reporting an incident to verifying the effectiveness of the remedial process

Many incidents have occurred because organisations have failed to learn from the lessons of the past. This means that there is ample room for improvement in the way organisations analyse incidents to identify technical, personal or organisational weaknesses and generate measures to remedy these weaknesses and prevent re- occurrence. The process from reporting an incident to verifying the effectiveness of these measures is called the ‘learning from incidents process’. In order to become safer, organisations use the outcome of incident analysis to optimise their primary, risk management and/or consequence mitigation process. However, organisational learning should not be limited to these processes alone but should also involve an evaluation of the ‘learning from incident process’ itself. An organisation with an effective ‘learning from incidents process’ sustains a process of continuous improvement that allows it to become intrinsically safer. To improve the learning from incidents process it is necessary to gain insight into the steps of this process and to identify potential or actual learning barriers. To analyse where the bottlenecks arise a model of eleven steps in four stages is proposed. This study describes how this model is used in a survey to locate the barriers and applied in three exploratory case studies in a range of industries. The results show that firstly not all organisations have the eleven steps formally organised and secondly that differences exist in what is formally arranged in an organisation and in how these steps work in practice. Whereas steps such as incident reporting and analysis are usually arranged and performed, follow-up steps in the process are often only arranged on paper or performed on a local level. The implications for the effectiveness of the ‘learning from incidents’ process are discussed.