It is important to learn from accidents in order to prevent similar ones from reoccurring. One of the elements of a successful organisation is the ability to learn from both success and failure, and the ability to learn from others.
During the past few years the ESReDA (European Safety, Reliability & Data Association) Project Group on Dynamic Learning has reflected on learning from accidents. The results are now available at the ESReDA website (project groups, dynamic learning).
The ESReDA project group on Dynamic Learning constructed a model which may be used to understand accidents more systematically. The ESReDA Cube model aims to analyse an accident from the point of view of how and what kind of lessons are learned, and what barriers to learning can be identified. The ESReDA Cube model may also be utilised to analyse the successes and failures of the accident investigation itself. Barriers to learning may be due to e.g. deficiencies in the investigation, reporting or follow-up. For example, learning requires follow-up on how the resulting recommendations for improvement are carried out.
The project group also composed guidelines to promote industrial accident investigation training and dynamic learning. The guidelines provide practical and theoretical advice related to different stages of event investigation and learning as a process. The guidelines discuss e.g. the different roles of accident investigators, investigation stages, and how to define the objectives of the investigation and choose an investigation method.
In addition, the website introduces a thought-provoking essay on investigation challenges. The essay is recommended to all investigators.
The Finnish Safety and Chemicals Agency (Tukes) is a member of the European safety organisation ESReDA and along with 11 other representatives from several European countries has been actively involved in the Project Group on Dynamic Learning. The other organisations involved in the project were EDP – Gestão da Produção de Energia, S.A. (Portugal), Institut de Radioprotection et de Sûreté Nucléaire (France), Électricité de France, Recherche & Développement (France), TNO (the Netherlands), Fondation pour une Culture de Sécurité FonCSI (France), SRL HSE-Consulting (Norway), Kindunos Safety Consultancy Ltd (the Netherlands), and the Joint Research Centre of the European Commission, the Netherlands (IET) and Italy (IPSC).
For more information:
Dr. Tuuli Tulonen, Senior Researcher, tel. +358 50 395 2884
Barriers to learning from incidents and accidents
Case study analysis on dynamic learning from accidents
Challenges to the Investigation of Occurrences Concepts and Confusion, Metaphors, Models and Methods
Guidelines for Preparing a Training Toolkit in Event Investigation and Dynamic Learning
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