Operational experience feedback and lessons learned are important sources of progress in safety management. A number of obstacles tend to decrease the effectiveness of learning from experience. We describe some symptoms of failure to learn, such as under-reporting and fixation on immediate causes, then describe underlying pathogenic organizational factors that can be responsible for the symptoms of ineffective learning.
From an operational standpoint, these slides aim to help practitioners to identify opportunities for improving their event learning process. They should be useful in the context of a process review of your organization’s learning system.
Barriers to learning from experience
We recommend the following sources of further information on this topic:
UK HSE report A survey of processes and systems for learning lessons from incidents within HSE and industry, UK Health and Safety Executive, 2005
ESReDA documents on Dynamic learning as the followup from safety investigations
FonCSI reports on operational experience feedback (in French) and its sociocultural success factors
RoSPA advice on learning from safety failure
Oxford Research Encyclopedia entry Collective Knowledge for Industrial Disaster Prevention