2015 ESREDA Barriers to learning from incidents and accidents
This document provides an overview of knowledge concerning barriers to learning from incidents and accidents. It focuses on learning from accident investigations, public inquiries and operational experience feedback, in industrial sectors that are exposed to major accident hazards. The document discusses learning at organizational, cross-organizational and societal levels (impact on regulations and standards). From an operational standpoint, the document aims to help practitioners to identify opportunities for improving their event learning process. It should be useful in the context of a process review of your organization’s learning system. Finally, it suggests a number of practices and organizational features that facilitate learning.
The main messages of the document are summarized below:
* Learning from unwanted events, incidents and accidents, in particular at an organizational level, is not as trivial as sometimes thought. Several steps are required to achieve learning: reporting, analysis, planning corrective actions, implementing corrective actions, and monitoring their effectiveness. Obstacles may appear within each step, and learning is not effective unless every step is completed. The obstacles may be technical, organizational or cultural.
* Learning from incidents, both as a formal company process and as an informal workgroup activity, is an opportunity for dialogue and collaborative learning across work groups and organizations. There may
be few other channels for communication on safety issues between industrial companies, subcontractors, labour representatives, regulators and inspectors, legislators and interested members of the public, but these actors need to work together more effectively on common problems.
* The implementation of an effective experience feedback process provides a strategic window for improving company equipment, operating procedures and organizational characteristics in an integrated
manner, allowing different perspectives to converge towards better preparation for the next event.
* There are known symptoms of failure to learn, which you may be able to recognize within your organization thanks to the diagnostic questions suggested in chapter 3.
* Symptoms of failure to learn often point to an underlying pathogenic condition (or a combination thereof) afflicting the culture of the organization. A number of known pathogenic organizational factors have been discussed in chapter 4.
* Experience from a number of industries which have a long history of incident reporting and learning shows that a number of enablers can overcome obstacles to learning. Chapter 5 provides a list of enablers that may be applicable in your industry and organization.