Title
What are the bottlenecks in the learning from incidents process?
Author
Drupsteen, L.
Steijger, D.J.M.
Groeneweg, J.
Zwetsloot, G.I.J.M.
TNO Kwaliteit van Leven
Publication year
2011
Abstract
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. Abbott Risk Consulting Ltd; Aker Solutions E + C Ltd; Centrica Plc; Resource Protection International Ltd
Subject
Workplace
Engineers
Environmental protection
Investigation and analysis
Learning from incidents
Remedial measures
Safety performance
Hazards
To reference this document use:
http://resolver.tudelft.nl/uuid:d493c0b2-bb86-45f8-8933-102ecb6eb200
TNO identifier
516461
ISBN
9781622767892
ISSN
0307-0492
Source
22nd Institution of Chemical Engineers Symposium on Hazards 2011: Process Safety and Environmental Protection, HAZARDS 2011, 11 April 2011 through 14 April 2011, Liverpool (156), 94-98
Series
Institution of Chemical Engineers Symposium Series
Document type
conference paper