Learning from Accidents

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

“…This can be partly attributed to the failure to learn from accidents [1,2,3,4]. The term "incident" refers to the combined set of occurrences of both accidents and near misses [5].…”

A study of the precursors leading to ‘organisational’ accidents in complex industrial settings

“…While the method employed here differs from this in detail, it uses the underlying approach of Grounded Theory to perform a qualitative metalevel ethnographic study to synthesise the learning already extracted from separate investigations which exist within often disparate engineering communities. Kletz (1994) demonstrates the power of accident narratives in understanding deep underlying influences, but it is in comparing these events and the synthesis of the subsequent recommendations that we see the similarities, the common underlying issues and actions. Thus, to arrive at the outputs presented here, a Grounded Theory inspired analysis and comparison of accident reports has been implemented using the lessons and recommendations of existing reports in order to identify those which occur most frequently across a range of industries The qualitative analysis was initially conducted independently by two of the authors following the practice established by Taylor and Rycraft (2004) .…”

Violent explosion after inadvertent mixing of nitric acid and isopropanol – Review 15years later finds basic accident data corrupted, no evidence of broad learning

“…Trevor Kletz in the book "What went wrong?" (Kletz 1988). A later book by the same author titled "Still going wrong" (Kletz 2003) hint that although learning from past accidents is a conceptually simple idea, major obstacles to practical implementation do exist and opportunities are foregone, see also Kletz (2004).…”