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

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Języki publikacji
EN
Abstrakty
EN
Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.
Rocznik
Strony
63--77
Opis fizyczny
Bibliogr. 39 poz., rys., tab., wykr.
Twórcy
autor
  • TNO Work and Employment, The Netherlands
autor
  • Leiden University, Leiden, The Netherlands
  • TNO Work and Employment, The Netherlands
  • TNO Work and Employment, The Netherlands
  • Institute of Work, Health and Organisations, Nottingham University, Nottingham, UK
Bibliografia
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  • 4.Kletz T. Learning from accidents. 3rd ed. Oxford, UK: Butterworth-Heinemann; 2001.
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  • 6.van Vuuren W. Organisational failure: an exploratory study in the steel industry and the medical domain [doctoral dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998. Retrieved December 14, 2012, from: http://alexandria.tue.nl/extra3/proefschrift/boeken/9800441.pdf.
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  • 8.Carpenter JK, Hendershot DC, Watts SJ. Learning from reactive chemistry incidents. Chem Health Saf. 2004;11(4):10–6.
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  • 23.Kolb DA. Experiential learning. Upper Saddle River, NJ, USA: Prentice Hall; 1984.
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  • 32.Barret JH, Haslam RA, Lee KG, Ellis MJ. Assessing attitudes and beliefs using the stage of change paradigm – case study of health and safety appraisal within a manufacturing company. Int J Ind Ergon. 2005;35(10):871–87.
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Typ dokumentu
Bibliografia
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