Barriers to learning from experience
Why do accidents tend to recur?

Overview

Symptoms and pathogens related to learning

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.