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Learning from accidents: what more do we need to know?
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
KTH, School of Architecture and the Built Environment (ABE), Philosophy.
2010 (English)In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 48, no 6, 714-721 p.Article in journal (Refereed) Published
Abstract [en]

A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.

Place, publisher, year, edition, pages
2010. Vol. 48, no 6, 714-721 p.
Keyword [en]
Experience feedback, Accidents, Incidents, Evaluation studies, Accident investigation, CHAIN model
National Category
Philosophy
Identifiers
URN: urn:nbn:se:kth:diva-8716DOI: 10.1016/j.ssci.2010.02.004ISI: 000278207300005Scopus ID: 2-s2.0-77951092240OAI: oai:DiVA.org:kth-8716DiVA: diva2:14113
Note
QC 20101118 Uppdaterad från manuskript till artikel (20101118).Available 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. viii, 10 p.
Series
Theses in risk and safety from the Division of Philosophy at the Royal Institute of Technology, ISSN 1654-627X ; 2
Keyword
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. vi, 42 p.
Series
Theses in philosophy from the Royal Institute of Technology, ISSN 1654-627X
Keyword
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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