Experience feedback from in-depth event investigations: How to find and implement efficient remedial actions

Abstract The present research focuses on the processes of identifying remedial actions subsequent to incidents at two Swedish nuclear power plants. Data from 106 in-depth analyses were analysed together with interviews with event investigators. The results and previous research in the domain indicated a need to further develop the process for identifying remedial actions. A method was developed that focuses on process descriptions and identifications of strengths and weaknesses inherent in the process(es) in which an incident occurred. The method uses a participatory approach with actors from the relevant process(es). A case study was conducted which showed promising results. The method is discussed in terms of generalising to a more process-oriented experience feedback than usually is applied.

[1]  Sven Ove Hansson,et al.  Learning from accidents : what more do we need to know? , 2010 .

[2]  W. Edwards Deming,et al.  The New Economics for Industry, Government, Education , 2018 .

[3]  E. Hollnagel,et al.  What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals , 2009 .

[4]  Sarah Maslen,et al.  Preventing black swans: incident reporting systems as collective knowledge management , 2016 .

[5]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[6]  J. L. Coze Disasters and Organisations: From Lessons Learnt to Theorising , 2008 .

[7]  Björn Wahlström,et al.  Safety management – A multi-level control problem ☆ , 2014 .

[8]  E. Hollnagel,et al.  The context and habits of accident investigation practices: A study of 108 Swedish investigators , 2010 .

[9]  C. Argyris On organizational learning , 1993 .

[10]  Erik Hollnagel,et al.  Resilience Engineering in Practice: A Guidebook , 2012 .

[11]  Rogier Woltjer,et al.  Resilience in Everyday Operations , 2013, Journal of Cognitive Engineering and Decision Making.

[12]  B. Turner Man Made Disasters , 1995 .

[13]  David Woods,et al.  Resilience Engineering: Concepts and Precepts , 2006 .

[14]  A. Margaryan,et al.  How organisations learn from safety incidents: a multifaceted problem , 2010 .

[15]  R. Lipshitz,et al.  Discerning the Quality of Organizational Learning , 2004 .

[16]  T. Davenport Saving IT's Soul: Human-Centered Information Management. , 1994 .

[17]  Carl Rollenhagen,et al.  Can focus on safety culture become an excuse for not rethinking design of technology , 2010 .

[18]  Urban Kjellen,et al.  Prevention of accidents through experience feedback , 2000 .

[19]  Joseph Moses Juran Juran on leadership for quality : an executive handbook , 1989 .

[20]  Dennis C. Hendershot,et al.  Incorporation of inherent safety principles in process safety management , 2007 .

[21]  Thomas R. Rohleder,et al.  Learning from incidents: from normal accidents to high reliability , 2006 .

[22]  Kristin Smith-Crowe,et al.  Relative effectiveness of worker safety and health training methods. , 2006, American journal of public health.

[23]  Chris W. Johnson,et al.  A survey of logic formalisms to support mishap analysis , 2003, Reliab. Eng. Syst. Saf..

[24]  Tor-Olav Nævestad,et al.  Safety Cultural Preconditions for Organizational Learning in High-Risk Organizations , 2008 .

[25]  N. Pidgeon,et al.  Man-made disasters: Why technology and organizations (sometimes) fail. , 2000 .

[26]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .