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Learning from accidents: Experience feedback in practice
KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology. (Filosofi)
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 [en]
Experience feedback, learning from accidents, incidents, near-accidents, CHAIN model, communication, dissemination
National Category
Philosophy
Identifiers
URN: urn:nbn:se:kth:diva-27212ISBN: 978-91-7415-772-7 (print)OAI: oai:DiVA.org:kth-27212DiVA: diva2:375929
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
List of papers
1. 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, 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.

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: 2017-12-14Bibliographically approved
2. 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, E-ISSN 1477-4003, 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: 2017-12-14Bibliographically approved
3. Learning from Experience in Municipal Environmental Supervision: A study of twenty-six Swedish supervion cases
Open this publication in new window or tab >>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
Supervision, inspection, experience feedback, municipal agencies, inter-agency cooperation
Identifiers
urn:nbn:se:kth:diva-27213 (URN)
Note
QC 20101209Available from: 2010-12-09 Created: 2010-12-09 Last updated: 2010-12-10Bibliographically approved
4. Accident prevention through experience feedback from the rescue services: A study of incident reports in Sweden
Open this publication in new window or tab >>Accident prevention through experience feedback from the rescue services: A study of incident reports in Sweden
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The fire and rescue services are called to the scene of almost all serious accidents. The purpose of this investigation was to find out whether the information they obtain in the course of their normal operations can be used to improve experience feedback in sectors where it is at present weak or non-existent. 1120 incident reports from two local Swedish fire and rescue services were studied. These reports contained 217 proposals for improvement. However, the reports are primarily intended for statistical purposes, and they are currently not used for experience feedback. A system for dissemination of such information is proposed. It is suggested that the rescue services are best equipped to transmit the relevant information to local recipients. A national authority can be entrusted with task to the review and collate information intended for non-local recipients such as companies whose products have been involved in accident and regulatory authorities whose safety regulations may need to be reassessed in light of the experiences reported.

Keyword
experience feedback, learning from accidents, prevention, fire and rescue services, incident report, intervention report
Identifiers
urn:nbn:se:kth:diva-27209 (URN)
Note
QC 20101209Available from: 2010-12-09 Created: 2010-12-09 Last updated: 2010-12-10Bibliographically approved
5. Investigating experience feedback in Swedish authorities: An empirical study of experience feedback practice in 21 Swedish authorities
Open this publication in new window or tab >>Investigating experience feedback in Swedish authorities: An empirical study of experience feedback practice in 21 Swedish authorities
(English)Manuscript (preprint) (Other academic)
Abstract [en]

This article focuses on practical experience feedback. Results from two interview studies are reported. In the first, experience feedback in different sectors in Sweden was investigated through interviews with 21 Swedish authorities involved in accident prevention. A result from this investigation was that the participating authorities in practice have a functioning experience feedback despite lack of systematic routines and methods. Yet, only four of the 21 participating authorities work with the whole experience feedback process. These four authorities have one common denominator; they have an experience feedback that is turning more inwards than outwards. All of the participating authorities have a need to improve and systematize the dissemination of experiences, knowledge and results. An improved dissemination can in fact affect other procedures such as the reporting of occurred accidents. Focus in this second study was on practical communication procedures, and how the authorities communicate results, knowledge and experiences within their own organisations, with other authorities, and with external parties. It is concluded that a more proactive approach would be valuable for the learning process.

Keyword
experience feedback, learning from accidents and incidents, communication, accident prevention
Identifiers
urn:nbn:se:kth:diva-27211 (URN)
Note
QC 20101209Available from: 2010-12-09 Created: 2010-12-09 Last updated: 2010-12-10Bibliographically approved

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