Learning from incidents: Practices at a Scandinavian refinery

Vastveit, Kirsti Russell; Boin, Arjen; Njå, Ove

doi:10.1016/j.ssci.2015.05.001

Cited by 21 publications

(5 citation statements)

References 38 publications

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“…As such, rather than naming different activities involved in LFI, the analysis will identify the qualities that are necessary for activities to effectively support learning. In an exploration of LFI practices at a refinery, Vastveit et al (2015) observed that learning occurred through structured activities and daily work tasks, supporting other studies that have found that workers learn about safety through praxis (Yap and Choy, 2018). The analysis will therefore consider both formal and informal learning processes.…”

Section: -P Model Of Workplace Learning In Lfisupporting

confidence: 71%

“…Often front-line teams will discuss the 'lessons learnt' from the incident and make sense of them in a way that is meaningful for their own work (Carroll, 1995). Additionally, individuals learn outside of formal incident meetings by reactively discussing unexpected events with colleagues (Vastveit et al, 2015). While the formal LFI process creates opportunities for individuals to reflect on the relevance of an incident to their own work, workers are continually making sense of incident-information as they encounter new situations in their daily practices.…”

Section: Learning From Incidentsmentioning

confidence: 99%

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Learning from incidents: applying the 3-P model of workplace learning

Murphy

Littlejohn

Rienties

2021

JWL

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Purpose Learning from incidents (LFI) is an organisational process that high-risk industries use following an accident or near-miss to prevent similar events. Literature on the topic has presented a fragmented conceptualisation of learning in this context. This paper aims to present a holistic taxonomy of the different aspects of LFI from the perspective of front-line staff. Design/methodology/approach The 3-P model of workplace learning was used to guide a thematic analysis of interview data from 45 participants, exploring learner factors, learning context, learning processes and learning products. Findings The analysis was used to create a taxonomy of 21 aspects of learning, grouped into themes using the 3-P model of workplace learning. Many of the aspects of learning reflected previous literature, such as the importance of open communication. The analysis additionally demonstrated the interconnected nature of organisational and individual level learning, as well as how formal resources are needed to support informal learning in this context. Originality/value This study presents a holistic taxonomy of LFI from the perspective of front-line staff, addressing a known challenge of LFI literature being fragmented. Additionally, it provides examples of how aspects of organisational learning would influence individual-level learning and vice versa, adding to the relatively sparse number of studies that have explored this aspect. Finally, the paper highlights how informal learning in contexts where workers continually need to make sense of unseen hazards depends on formal learning activities and resources.

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Section: -P Model Of Workplace Learning In Lfisupporting

confidence: 71%

Section: Learning From Incidentsmentioning

confidence: 99%

Learning from incidents: applying the 3-P model of workplace learning

Murphy

Littlejohn

Rienties

2021

JWL

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“…Near-miss reporting and analysis, and the implementation of adequate corrective measures based on investigation results, can prevent the recurrence of near-misses and accidents with the same root cause. Near-misses can be used for learning about and the prevention of possible accidents [1].…”

Section: Introductionmentioning

confidence: 99%

Reporting as a Key Element of an Effective Near-Miss Management System in Shipping

Hasanspahić

Frančić

Vujičić

et al. 2020

Safety

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Shipping is a high-risk industry and prone to accidents. A near-miss management system is an important aspect of the safety performance in shipping because the causes are the same for near-misses and accidents. Reporting, analyzing, and learning from near-misses can prevent the recurrence of accidents and thus improve safety on ships. This paper addresses near-miss management systems in shipping and provides insights into the quality of the implementation of these systems, with an emphasis on the importance of reporting. Research data were derived from two surveys and supported by data gained from near-miss reports and existing literature reviews. Professional seafarers of various ranks, ages, nationalities, and experiences, serving on tankers, cruise ships, bulk carriers, and container ships, voluntarily participated in these surveys. The first survey comprised 223 participants, and the second survey involved 22 participants. The research results indicate that near-miss reporting is inadequate, and several barriers limit appropriate near-miss reporting. The difficulty of seafarers in identifying near-miss events was found to be one of the major barriers to near-miss reporting at sea. Based on this research, a conceptual model of a near-miss management system was developed, and measures that can be applied to overcome barriers and increase reporting are proposed.

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“…The next phase of the research program involves inviting the whole sector to evaluate of the feasibility of the prevention strategies. However, it is acknowledged that even if the prevention strategies are favorably assessed by the sector, there are many factors that will influence their implementation (e.g., Pidgeon and O'Leary, 2000; Lundberg et al, 2010, 2012; Ramanujam and Goodman, 2011; Le Coze, 2013; Vastveit et al, 2015). A direction for future research is to chart the barriers to implementing system reforms that exists within the LOA sector.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, there is a significant body of research examining the factors influencing initial reporting, and the selection, implementation and maintenance of prevention strategies (e.g., Pidgeon and O'Leary, 2000; Lundberg et al, 2010, 2012; Ramanujam and Goodman, 2011; Le Coze, 2013; Vastveit et al, 2015). However, little research has focused on the process of designing prevention strategies, or describing the prevention strategies that result.…”

Section: Introductionmentioning

confidence: 99%

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

et al. 2016

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Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

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Learning from incidents: Practices at a Scandinavian refinery

Cited by 21 publications

References 38 publications

Learning from incidents: applying the 3-P model of workplace learning

Learning from incidents: applying the 3-P model of workplace learning

Reporting as a Key Element of an Effective Near-Miss Management System in Shipping

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

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