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Experience feedback in practice
KTH, School of Architecture and the Built Environment (ABE), Philosophy.
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 [en]
Experience feedback, accidents, incidents, accident investigations, CHAIN model, learning process.
National Category
Philosophy
Identifiers
URN: urn:nbn:se:kth:diva-4817ISBN: 978-91-7178-988-4 (print)OAI: oai:DiVA.org:kth-4817DiVA: diva2:14115
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
List of papers
1. Evaluating the effectiveness of an investigation board for workplace accidents
Open this publication in new window or tab >>Evaluating the effectiveness of an investigation board for workplace accidents
2006 (English)In: Policy and Practice in Health and Safety, ISSN 1477-3996, Vol. 4, no 1, 63-79 p.Article 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.

Keyword
Accident, accident investigation, CHAIN model, Sweden, workplace inspection, workplace safety
National Category
Philosophy
Identifiers
urn:nbn:se:kth:diva-8715 (URN)
Note
QC 20101118Available from: 2008-06-09 Created: 2008-06-09 Last updated: 2010-12-09Bibliographically approved
2. Learning from accidents: what more do we need to know?
Open this publication in new window or tab >>Learning from accidents: what more do we need to know?
2010 (English)In: Safety Science, ISSN 0925-7535, 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.

Keyword
Experience feedback, Accidents, Incidents, Evaluation studies, Accident investigation, CHAIN model
National Category
Philosophy
Identifiers
urn:nbn:se:kth:diva-8716 (URN)10.1016/j.ssci.2010.02.004 (DOI)000278207300005 ()2-s2.0-77951092240 (Scopus ID)
Note
QC 20101118 Uppdaterad från manuskript till artikel (20101118).Available from: 2008-06-09 Created: 2008-06-09 Last updated: 2010-12-09Bibliographically approved
3. Learning from experience in municipal environment inspection
Open this publication in new window or tab >>Learning from experience in municipal environment inspection
2008 (English)Article in journal (Other academic) Submitted
Keyword
Inspection, environmental inspection, experience feedback, municipal agencies, inter-agency cooperation
National Category
Philosophy
Identifiers
urn:nbn:se:kth:diva-8717 (URN)
Note
QS 20120314Available from: 2008-06-09 Created: 2008-06-09 Last updated: 2012-03-14Bibliographically approved

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