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 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
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Learning from incidents and accidents |
Other resources
We recommend the following sources of further information on this topic:
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UK HSE report A survey of processes and systems for learning lessons from incidents within HSE and industry, UK Health and Safety Executive, 2005
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Operational Experience Feedback resources at nuclear-safety.info
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Energy Institute Guidance Learning from incidents, accidents and events
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ESReDA documents on Dynamic learning as the followup from safety investigations
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World Bank report Capturing solutions for learning and scaling up: Documenting Operational Experiences for Organizational Learning and Knowledge Sharing