Learning from incidents and accidents
The gift of failure

Overview

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 and near misses 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)

Other resources

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

• Operational Experience Feedback resources at nuclear-safety.info

• RoSPA resources on learning from safety failure

• A white paper on learning from adverse events by the UK Chartered Institute of Ergonomics and Human Factors (CIEHF)

• ESReDA documents on Dynamic learning as the followup from safety investigations

• Canadian TSB video on the Lac Mégantic railway disaster

• IRSN video on the Fukushima-Daiichi nuclear accident

• A collection of plane crash writeups by “Admiral Cloudberg”

• World Bank report Capturing solutions for learning and scaling up: Documenting Operational Experiences for Organizational Learning and Knowledge Sharing

• Energy Institute Guidance Learning from incidents, accidents and events (website registration needed)