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What are the bottlenecks in the learning from incidents process?

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Author: Drupsteen, L. · Steijger, D.J.M. · Groeneweg, J. · Zwetsloot, G.I.J.M.
Institution: TNO Kwaliteit van Leven
Source:22nd Institution of Chemical Engineers Symposium on Hazards 2011: Process Safety and Environmental Protection, HAZARDS 2011, 11 April 2011 through 14 April 2011, Liverpool, 156, 94-98
Institution of Chemical Engineers Symposium Series
Identifier: 516461
ISBN: 9781622767892
Keywords: Workplace · Engineers · Environmental protection · Investigation and analysis · Learning from incidents · Remedial measures · Safety performance · Hazards


The main purpose of our ongoing study is to develop knowledge on how to improve learning from incidents in organisations. In this phase of the study insight into the main bottlenecks is created. Many organizations investigate accidents and incidents to understand what happened, what caused it and why, and how to learn lessons from them to prevent re-occurrence. No matter how accurate the investigation and analysis are: further steps are necessary to prevent re-occurrence. By learning from incidents, re-occurrence of these incidents and the occurrence of similar events can be prevented and therefore safety performance can be improved. In an earlier phase of the study a model of the learning from incidents process, which is the process from reporting an incident to verifying the effectiveness of remedial measures, is developed. A survey was performed to locate where the main bottlenecks arose. In this paper the types of bottlenecks that hinder the learning from incidents process will be described. Abbott Risk Consulting Ltd; Aker Solutions E + C Ltd; Centrica Plc; Resource Protection International Ltd