Research and development agenda for Learning from Incidents

Abstract

This paper outlines a research and development agenda for the nascent field of Learning from Incidents (LFI). Effective, deep and lasting learning from incidents is critical for the safety of employees, the general public and environmental protection. The paper is an output of an international seminar series 'Interdisciplinary Perspectives on Learning from Incidents' funded by the UK Economic and Social Research Council (ESRC) in 2013-2016 http://lfiseminars.ning.com/ The seminar series brought together academics, practitioners and policymakers from a range of disciplines and sectors to advance the theory, methodology, organisational practice and policy in LFI. Drawing on a range of disciplinary and sectoral perspectives, as well as on input from practitioners and policymakers, this paper lays out four key research and development challenges: defining LFI; measuring LFI; levels and factors of LFI; and strengthening research-practice nexus in LFI.Keywords: learning from incidents; learning from accidents; learning from near-misses; organisational learning; adult learning; workplace learning Highlights:• Interdisciplinary research is critical to advancing our understanding of learning from incidents • Integration should be a core activity in future research and development in LFI • R&D areas are defining and measuring LFI; differentiating LFI levels; strengthening research-practice link in LFI.

Human, Technologies and Quality of Education, 2019

“…Occurrence of incidents is unavoidable and even a minor incident can provide valuable feedback for improvement of safety, quality and management in the organisation (Westhuizen, Stanz, 2017;Staender, 2011). Staender (2011), Margaryan, Littlejohn, (2016) and Stemn, Bofinger, (2018) discuss the concept of "learning from incidents", which means that the organisation can learn from unexpected safety events to prevent similar such events that may happen in the future. This may be applicable not only to safety events, but any incidents, that cause any kind of losses.…”

“…Nowadays the concept is applied in variety of industries, such as manufacturing, aviation, healthcare, transport, banking and finance, etc. (Margaryan, Littlejohn, 2016;Staender, 2011). Incident reporting provides the opportunity to reveal the weaknesses that allowed incident to happen and to act upon it to make required improvements (Staender, 2011;Chapelle, 2019).…”

“…The effective process contains important steps, which include reporting of incident, thorough investigation to identify and analyse the root causes of the incident and then drawing out recommendations and "learning points", that are used for implementation of required changes in order to prevent the same incident from re-occurring (Staender, 2011;Margaryan, Littlejohn, 2016;Stemn, Bofinger, 2018). Staender (2011) compares incident reporting to the storytelling and states that these reports can be collected by an organisation as documented experience used for applying necessary improvements.…”

“…Another important step in incident management is to communicate the required changes in human behaviour or processes to relevant responsible stakeholders, as without good communication implementation of changes (or mitigation actions) will not be effective and may not take place at all, if not addressed to the key responsible people in the organisation. The communication channels can be reports, internal regulations and manuals for employees, notice boards, notification e-mails, team discussions (Margaryan, Littlejohn, 2016). Stemn, Bofinger (2018) noted that learning from incidents is the key for achieving high levels of safety in organisations.…”

“…The concept of incident management was established, and in some cases even is regulated by law, in such industries like banking, healthcare, aviation, construction, rail, energy, manufacturing, maritime, etc. (Margaryan, Littlejohn, 2016;Canham, Jun, 2018;Staender, 2011). Incident management is needed in order to improve organisation's performance and internal control environment; it is important to know what particular incidents occur in the organisation to be able to identify weakness points and possible breaches (Chapelle, 2019).…”