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Evaluating the effectiveness of an investigation board for workplace accidents
KTH, School of Architecture and the Built Environment (ABE), Philosophy.
KTH, School of Architecture and the Built Environment (ABE), Philosophy.ORCID iD: 0000-0003-0071-3919
2006 (English)In: Policy and Practice in Health and Safety, ISSN 1477-3996, E-ISSN 1477-4003, Vol. 4, no 1, p. 63-79Article in journal (Other academic) Published
Abstract [en]

This paper examines the activities of the Swedish Work Environment Authority's Accident Investigation Board. It first gives an outline of the board's role and a summary of the previous literature on accident investigation. It then proposes an investigation methodology, the CHAIN model, which forms the theoretical point of departure of the paper. It describes the methods used in the empirical study, and examines the board's investigation criteria and how these were implemented. A summary of the effects of the board's reports on affected companies is presented, along with a survey of SWEA inspectors and interviews with workplace inspectors and others who have an interest in workplace accident investigation. Finally, the study's results are compared to the CHAIN model, with the conclusions that:  

• the board has been successful in establishing a high qualitative standard for investigating workplace accidents  

• the investigation process should be speeded up if the board's reports are to realise their full potential  

• dissemination of the reports must be improved, and a follow-up system is needed.

Place, publisher, year, edition, pages
2006. Vol. 4, no 1, p. 63-79
Keywords [en]
Accident, accident investigation, CHAIN model, Sweden, workplace inspection, workplace safety
National Category
Philosophy
Identifiers
URN: urn:nbn:se:kth:diva-8715OAI: oai:DiVA.org:kth-8715DiVA, id: diva2:14112
Note
QC 20101118Available from: 2008-06-09 Created: 2008-06-09 Last updated: 2017-12-14Bibliographically approved
In thesis
1. Experience feedback in practice
Open this publication in new window or tab >>Experience feedback in practice
2008 (English)Licentiate thesis, comprehensive summary (Other scientific)
Abstract [en]

The subject of this licentiate thesis is experience feedback from accidents and incidents. The thesis aims to contribute to an understanding of how the learning processes within organizations, companies and authorities could be improved.

Essay I (written together with Sven Ove Hansson) reports on an evaluation carried out in 2004 by the Swedish Work Environment Authority’s Accident Investigation Board, called HAKO (Haverikommissionen). An important outcome of this evaluation shows that HAKO have not been able to manage the dissemination of their written reports, which is unfortunate, since the reports are thoroughly written.

Essay II (written with Sven Ove Hansson and Carl Rollenhagen) is an overview of the literature on learning from accidents and incidents. The focus in this essay is on literature that evaluates the effectiveness and usefulness of different methods in accident investigations. The conclusions drawn from this literature review are that the dissemination of results and knowledge from accident investigations must be improved, and experience feedback systems should be integrated into overall systems of risk management.

The starting point for Essay III was an empirical study conducted in 2005/2006. Twenty-eight supervision cases from eleven local Environment and Health Administrations in Sweden were examined. The overall goal of the study was to find out how, and to what extent, experience feedback occurs between different municipal authorities. Two major problems affecting experience feedback have been found; namely, that the inspectors do not have enough guidance on how to interpret the law, and that they would like more information on what happens to legal cases they have reported to public prosecutors and police.

Place, publisher, year, edition, pages
Stockholm: KTH, 2008. p. viii, 10
Series
Theses in risk and safety from the Division of Philosophy at the Royal Institute of Technology, ISSN 1654-627X ; 2
Keywords
Experience feedback, accidents, incidents, accident investigations, CHAIN model, learning process.
National Category
Philosophy
Identifiers
urn:nbn:se:kth:diva-4817 (URN)978-91-7178-988-4 (ISBN)
Presentation
2008-06-13, Rum 231, KTH, Teknikringen 78 B, Stockholm, 13:00
Opponent
Supervisors
Note
QC 20101118Available from: 2008-06-09 Created: 2008-06-09 Last updated: 2010-11-18Bibliographically approved
2. Learning from accidents: Experience feedback in practice
Open this publication in new window or tab >>Learning from accidents: Experience feedback in practice
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Experience feedback from accidents is important for preventive work in companies, authorities and other organisations. This thesis focused on experience feedback from accidents that take place in everyday life, in our neighbourhoods, in our workplaces, in our schools, in traffic and transportation.

Essay I is an overview of the literature on learning from accidents and incidents. The focus in this essay is on literature that evaluates the effectiveness and usefulness of different methods in accident investigations. Conclusions drawn from this literature review are that the dissemination of results and knowledge from accident investigations must be improved, and experience feedback systems should be integrated into overall systems of risk management.

Essay II is based on an evaluation of the investigation board for workplace accidents (HAKO) that was carried out on commission of the Swedish Work Environment Authority. It was concluded that the accident reports published by HAKO had a high qualitative level but the dissemination of results from the investigations was weak.

Essay III investigates twenty-eight supervision cases from eleven Swedish local Environment and Health Administrations. The overall goal of the study was to find out how, and to what extent, experience feedback occurs in Swedish municipalities. Two major problems relevant for the experience feedback have been found; namely that the inspectors do not have enough guidance on how to interpret the law and that they would like more information on what happens to legal cases that they have handed over to the public prosecutors and the police.

Essay IV is a document study of incident reports from two municipal fire and rescue services. The overall purpose of this study was to investigate if information from the rescue services could be used to improve experience feedback in sectors where it is weak or non-existent. In the 1120 incident reports that were studied, we found 217 proposals for improvement but these proposals were not used for experience feedback. It is concluded that the reports contain valuable information but this information is not used to prevent future accidents.

Essay V investigates experience feedback in Swedish authorities working with accident prevention. The essay is based on two interview studies. In the first study, 21 Swedish authorities participated, and several of these authorities seem to have a functioning experience feedback despite the lack of systematic routines and methods. Yet, only four of the 21 authorities actually handle the whole experience feedback process. These four have at least one common denominator; they have an experience feedback that is turning more inwards than outwards. The second study was a follow-up study of some of the results from the first study, concerning the dissemination of results from experience feedback.

Place, publisher, year, edition, pages
Stockholm: KTH, 2010. p. vi, 42
Series
Theses in philosophy from the Royal Institute of Technology, ISSN 1654-627X
Keywords
Experience feedback, learning from accidents, incidents, near-accidents, CHAIN model, communication, dissemination
National Category
Philosophy
Identifiers
urn:nbn:se:kth:diva-27212 (URN)978-91-7415-772-7 (ISBN)
Public defence
2010-12-17, D3, Lindstedtsvägen 5, KTH, Stockholm, 10:00 (English)
Opponent
Supervisors
Note
QC 20101209Available from: 2010-12-09 Created: 2010-12-09 Last updated: 2010-12-09Bibliographically approved

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