Risk Engineering

Learning from incidents and accidents
The gift of failure


Overview

The
operational experience feedback loop

Learning from accidents is the acquisition of knowledge and skills from a thorough study of accidents and their antecedents. The knowledge acquired may concern the types of unwanted events which may occur, the factors that can contribute to these unwanted events, the barriers which can prevent their occurrence, the possible consequences of the unwanted events, and the protective measures which can limit their consequences.

Operational experience feedback is a structured process aiming to learn from past events in order better to control the future:

  • collect information on anomalies, deviations, near misses, incidents and accidents
  • analyze the sequence of events and their causality
  • extract new knowledge or learning from the analysis
  • implement corrective actions or action plans
  • share the learning with all interested parties
  • record the learning so that it can help people in the future

This module describes how organizations can implement an operational experience feedback process, and discusses a number of barriers to learning which hinder the effectiveness of this process in improving safety in the long term.

Course material

Learning from incidents and accidents

Lecture slides (PDF)
View on SlideShare

Other resources

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