Failure to learn from safety incidents: Status, challenges and opportunities

Stemn, Eric; Bofinger, Carmel; Cliff, David; Hassall, Maureen

doi:10.1016/j.ssci.2017.09.018

Cited by 75 publications

(60 citation statements)

References 58 publications

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“…The result further showed a significant correlation between unsafe act as an incident causal factor and identifying the person who caused the incident as a reason for initiating investigation. This implies those whose investigations focus on unsafe acts tend to focus their attention on the worker, something which has been identified as a key contributor of the blame culture and an inhibitor of effective investigations [11,51]. This is because investigation attention is diverted from the root causes deeply buried within the organization.…”

Section: Discussionmentioning

confidence: 99%

“…This was an iterative process, involving going back to already coded text to compare codes. This inductive coding was repeated for all 41 interviews, with codes being constantly compared to remove redundant codes and group similar codes, until a coding structure applicable to all the interviews was developed [11]. This led to the identification of 5 and 9 categories of incident causal factors and reasons for investigating incidents, respectively.…”

Section: Interviewsmentioning

confidence: 99%

“…Some of the issues identified included lack of investigation training, lack of knowledge on accident causation models, limited use of relevant information/data sources, and using the investigation process to identify violation to recommend punishment. Again, it has been reported that the perceptions of ordinary workers concerning incident investigations affect the investigation culture of the organization and the individual commitment toward incidents investigations [11,26,27]. However, those past studies report the perspectives of workers deeply involved in incident investigations, without any considerations to the perspectives of ordinary workers with no investigation responsibilities.…”

Section: Introductionmentioning

confidence: 98%

“…Again, incident investigations suggest that incidents are analyzed to identify lessons (the causal factors that contributed to the incidents), and, on the basis of identified lessons, recommendations, which when acted upon can prevent future incidents, are formulated and implemented [7][8][9][10]. Therefore, incidents must not be seen as dissatisfactions, but rather as a learning input, a free lesson, and a potential opportunity to focus efforts to improve the current organizational safety level [11]. These and several other reasons have accounted for the recent focus and growing interest in incident investigation research.…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Incident Causal Factors and the Reasons for Conducting Investigations: A Study of Five Ghanaian Large-Scale Mines

Stemn

Ntsiful

Azadah

et al. 2020

Safety

Self Cite

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Background: This research sought to understand the perspective of mineworkers regarding incident investigations, with the objective of identifying incident investigations improvement opportunities. First, through interviews, the research sought to identify the causal factors considered during investigations and the reasons for conducting investigations in the Ghanaian mining industry. Secondly, through questionnaire surveys, the study focused on understanding the extent to which a large sample of mineworkers considered the identified causal factors and investigation reasons relevant and applicable in their mine. Method: Data were collected from 41 participants through interviews and 659 respondents through surveys, and the data were analyzed through thematic, content, and statistical analyses, including descriptive statistics, one-way ANOVA, and correlation analysis. Result: The interviews led to the identification of five and nine categories of incident causal factors and reasons for investigating incidents, respectively. The results suggested a focus on workers’ unsafe acts as the main incident causal factor and identifying the person who caused the incident as one of the major reasons for investigating incidents, as these two factors where the modal choice from both the interviews and survey across all five mines. The results further showed that concerning the accident causal factors and the reasons for investigating incidents, no significant difference was observed between the perspectives of mineworkers involved in investigations and mineworkers with no investigation responsibilities. Conclusion: It can be concluded from the results that talking to ordinary mineworkers does not generate innovative safety responses in this context, as the workers believe whatever they are taught, without critiquing it. Again, the focus on workers’ behavior as an accident causal factor is an indication of single-loop learning in contrast to double-loop learning, and its implication as well as opportunities to strengthen incident investigation focusing on improving organizational safety have been discussed.

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Section: Discussionmentioning

confidence: 99%

Section: Interviewsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Incident Causal Factors and the Reasons for Conducting Investigations: A Study of Five Ghanaian Large-Scale Mines

Stemn

Ntsiful

Azadah

et al. 2020

Safety

Self Cite

View full text Add to dashboard Cite

show abstract

“…Their analyses revealed that clearly stated rationale, proper assignment of roles, and well‐established procedures facilitate the IS, while limited SA and incapacitated expression of information impede it. Complementarily to this research, Stemn et al examined the process of learning from safety incidents to determine potential points of its improvement.…”

Section: Related Workmentioning

confidence: 99%

Threat intelligence platform for the energy sector

Wróbel

2019

Softw Pract Exp

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In recent years, critical infrastructures and power systems in particular have been subjected to sophisticated cyberthreats, including targeted attacks and advanced persistent threats. A promising response to this challenging situation is building up enhanced threat intelligence (TI) that interlinks information sharing and fine-grained situation awareness. In this paper, a framework that integrates all levels of TI, ie, strategic, tactical, operational, and technical, is presented. The platform implements the centralized model of information exchange with peer-to-peer interactions between partners as an option. Several supportive solutions were introduced, including anonymity mechanisms or data processing and correlation algorithms. A data model that enables communication of cyberincident information, both in natural language and machine-readable formats, was defined. Similarly, security requirements for critical components were devised. A pilot implementation of the platform was developed and deployed in the operational environment, which enabled practical evaluation of the design. Also, the security of the anonymity architecture was analyzed.

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Beyond blame: A systemic accident analysis through a neutralized human factors taxonomy

Stefana,

De Paola,

Snaiderbaur Bono

et al. 2024

Hum Ftrs & Erg Mfg Svc

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This paper investigates the usage of a systemic neutralized taxonomy for understanding human factors to foster a restorative culture when studying adverse events. The available studies supporting accident analysis from a system‐theoretic perspective with human factors‐based methods are grounded on error taxonomies and do not reinforce the non‐judgemental dimension that is encouraged by modern safety science. We propose a methodology to integrate the system‐theoretic accident analysis technique, Causal Analysis based on System Theory, with a neutralized taxonomy of human explanatory factors. The proposed methodology has been applied to an aviation accident involving a military aircraft and a glider. This case revealed various critical interactions among system components, which require dedicated safety recommendations that go beyond the identification of single points of failures and root causes, leading to a deeper understanding of socio‐technical orchestrations. Despite the use case in aviation, the proposed methodology remains suitable for various types of safety occurrences in diverse domains and industrial settings. It also represents the basis for supporting future proactive safety‐related decision‐making processes.

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Failure to learn from safety incidents: Status, challenges and opportunities

Cited by 75 publications

References 58 publications

Incident Causal Factors and the Reasons for Conducting Investigations: A Study of Five Ghanaian Large-Scale Mines

Incident Causal Factors and the Reasons for Conducting Investigations: A Study of Five Ghanaian Large-Scale Mines

Threat intelligence platform for the energy sector

Beyond blame: A systemic accident analysis through a neutralized human factors taxonomy

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