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Learning from Experience in Municipal Environmental Supervision: A study of twenty-six Swedish supervion cases
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Twenty-six supervision cases from eleven Swedish municipal Environment and Health Administrations were examined. This was made in order to determine how and to what extent experience feedback and other exchange of experiences take place among municipal environment authorities and to identify unfulfilled demands of such communication. There was a remarkable lack of demand for classical experience feedback in which information from technological and organizational failures was used to avoid a repetition of the same type of failure. Instead, inspectors expressed a need for exchanges from other agencies dealing with similar issues and a need for systematic feedback from public prosecutors of cases that have been handed over to them.

Keyword [en]
Supervision, inspection, experience feedback, municipal agencies, inter-agency cooperation
URN: urn:nbn:se:kth:diva-27213OAI: diva2:375904
QC 20101209Available from: 2010-12-09 Created: 2010-12-09 Last updated: 2010-12-10Bibliographically approved
In thesis
1. 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.
Theses in philosophy from the Royal Institute of Technology, ISSN 1654-627X
Experience feedback, learning from accidents, incidents, near-accidents, CHAIN model, communication, dissemination
National Category
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)
QC 20101209Available from: 2010-12-09 Created: 2010-12-09 Last updated: 2010-12-09Bibliographically approved

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