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ABSTRACT

This paper reports on a study of practices used to learn from incidents with the aim of improving safety performance in a Scandinavian refinery. Data for the study was collected during five months of fieldwork at the refinery and interviews with 70 refinery employees. In this paper, we examine how managers, engineers and operators at the refinery participated in activities aimed at learning from incidents. Incident learning did not just happen through formal incident management processes, but also through daily work practices. Hence, workplace learning may be an interesting lens through which to examine employee practices to learn from incidents. We found that employees executed learning-related tasks in different ways from formal presentation of reports and risk reducing measures to informal meetings and discussion raising the reflexivity of employees. We conclude this paper with recommendations for learning practices in large-scale industrial environments.

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From the full-text paper:

This study identified and discussed the following key findings:

• Many employees were engaged in learning (which was said to be a “messy” process with many varied opinions on how the organisation learned from incidents).
• Some employees thought that the incident management process sometimes interfered with learning. One person remarked that learning doesn’t necessarily have the central focus of investigations but rather more “case management”. That is, dealing with the incident and moving on in a non-systematic way.
• Several employees wished they had more time to work on the follow-up items after incidents to help prevent other incidents.
• Incident analysis practices between employees varied considerably. Incident Managers said that they mostly recorded causes related to their own organisational level and not commonly other units, like engineering or modifications. Thus, things like design issues may go relatively unexplored.
• The incident management software constrained and framed the types of causes “found” in investigations. People would select from a limited set of immediate causes; underlying causes were not commonly added via free-text.
• When asked what types of measures people frequently add to the incident system (human, technical or organisational causes), a respondent said that they mostly focus on the things that they can personally do something about. Measures/actions typically focus on front-line operators and rarely do they ever address upstream leadership, system or organisational factors.
• On the above, an incident manager said ‘‘No, it is rare to write something about leadership. . .maybe we do not have a culture for it, so you could say that the incident system largely has been aimed at the operators’’ (p83).
• When adding corrective actions/measures to the incident system, it was recognised that is wasn’t common for there to be any follow-up to check if the measures had been properly executed or were even effective for their purpose. That is, the incident management system was rarely used to check if measures had their desired effects.
• People tended to fall back on previous measures when incidents reoccurred. Measures like toolboxes/discussing incidents in meeting tended to be a common measure.
• Lessons were individually translated to work practices (lessons became part of individual of group working practices and were not necessarily formalised in organisational measures).
• Little training regarding learning from incidents (at this refinery little training was provided in how to learn from lessons; but this may more reflect learning as part of everyday work practices instead of transcribed into formal training).
• Measures from less severe incidents were typically aimed at fixing technical or operator issues (learning at this refinery appeared to be more focussed around single-loop learning from immediate contributors instead of learning at a more systems level, e.g. double-loop).
• Learners had different needs (given the different learning needs people have, the authors state that whereas some of the learning process can be accomplished through the sharing of existing knowledge, other learning processes may require the creative development of new knowledge by individuals and groups).

Authors: Vastveit, K.R., Boin, A., & Njå, O. (2015), Safety Science, 79, 80-87.

Study link: https://doi.org/10.1016/j.ssci.2015.05.001

Link to the LinkedIn article: https://www.linkedin.com/pulse/learning-from-incidents-practices-scandinavian-ben-hutchinson