Methodology for Assessing Learning from Incidents - a Process Industry Perspective
Author
Summary, in English
Several aspects of learning need to be included in a methodology for a comprehensive assessment of how effectively the learning from incidents works. One has to be able to address the following types of issues:
1. Do we handle the incidents reported in our incident learning system properly? Do the various steps in the learning cycle work effectively?
2. How much do we learn from the incidents which are reported? How does this learning compare with what could potentially have been extracted? What level of learning are we at and what level could we have achieved?
3. Do we report the incidents that are worth reporting (that have a learning potential)? What is the threshold for reporting? How big is the number of unreported cases, the “hidden number”?
In order to address issue 1, a method has been developed which assesses the effectiveness of learning in every step of the learning cycle (Reporting – Analysis – Decision – Implementation – Follow-up) for each incident, and of the aggregated material of many incidents. The method contains a tool for each step, built on a number of dimensions which in turn contain a number of aspects. By using a rating system including a scale with formulated requirements for some levels, the effectiveness of each step can be assessed numerically for each individual incident.
For issue 2, a method has also been developed that builds on classifying the learning product, the measures taken, in different levels depending on how well the experiences from an incident are handled. The basis for classifying an incident is the geographical application, the degree of organisational learning, and the duration of the measures taken. Incidents are classified both in actual levels of learning based on the measures taken, and in potential levels of learning, indicating the level that could have been achieved if all the potential for learning had been utilised. The relation (the ratio) between actual and potential levels of learning is a measure of the effectiveness of the learning. A specific method for evaluating the underlying causation has been developed to draw conclusions about the potential learning.
For issue 3, a tool has been developed for assessing the threshold for reporting as well as guidelines for what can be considered reasonable frequencies of incident reporting in the process industry. In addition to providing information about how efficient the reporting of incidents is, this will also provide input to the method for issue 2.
Together, the methods with their tools and guidelines constitute a methodology, which allows the user to make a total assessment of the effectiveness of the learning from incidents in process industry companies.
The empirical material for the research was taken from the incident databases of six Swedish process industry companies, and from the EC MARS database for major accidents in enterprises which fall under the Seveso legislation.
The results from the application of the methods have proven that learning from incidents is often limited, especially in relation to what would have been possible to achieve. Effectiveness in the learning cycle is often relatively poor, especially in the analysis and the follow-up steps.
The results from the assessment of the learning effectiveness combined with the results from safety audits often offer valuable insight into the decisive factors for good learning.
Department/s
Publishing year
2011
Language
English
Full text
Document type
Dissertation
Publisher
Lund University/EAT
Topic
- Engineering and Technology
Keywords
- Accidents
- Incidents
- Learning from incidents
- Learning cycle
- Lesson learned
- Process industry
Status
Published
Supervisor
ISBN/ISSN/Other
- ISBN: 978-91-7473-128-6
Defence date
1 June 2011
Defence time
10:15
Defence place
Stora hörsalen, Department of Design Sciences, Ingvar Kamprad Designcentrum, Sölvegatan 26, Lund University Faculty of Engineering
Opponent
- Jan Hovden (Professor)