Research and Development Agenda for Learning from Incidents

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.

[1]  Allen F. Repko,et al.  Interdisciplinary Research: Process and Theory , 2011 .

[2]  Ignacio. Farías Misrecognizing Tsunamis: Ontological Politics and Cosmopolitical Challenges in Early Warning Systems , 2014 .

[3]  Gisa Weszkalnys Anticipating Oil: The Temporal Politics of a Disaster Yet to Come , 2014 .

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

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

[6]  Y. Engeström,et al.  The change laboratory as a tool for transforming work , 1996 .

[7]  Geoffrey W. McCarthy Human factors methods and accident analysis. Practical guidance and case study applications , 2013 .

[8]  A. Hopkins,et al.  Thinking About Process Safety Indicators , 2007 .

[9]  Howard J. Gordon,et al.  Integrating Learning Into Safety Developing a Robust Lessons-learned Program , 2008 .

[10]  Donald L. Kirkpatrick,et al.  Evaluating Training Programs. The Four Levels. Berrett-Koehler Organizational Performance Series. , 1994 .

[11]  Linda Drupsteen-Sint,et al.  Improving organisational safety through better learning from incidents and accidents , 2014 .

[12]  Neville A. Stanton,et al.  Engineering psychology: contribution to system safety , 1997 .

[13]  Ingrid Bouwer Utne,et al.  Building Safety indicators: Part 2 - Application, practices and results , 2011 .

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

[15]  David Denyer,et al.  What learning happens? Using audio diaries to capture learning in response to safety-related events within retail and logistics organizations , 2016 .

[16]  Johan M. Sanne,et al.  Learning from adverse events in the nuclear power industry: Organizational learning, policy making and normalization , 2012 .

[17]  F. Ricci,et al.  Effectiveness of occupational health and safety training: A systematic review with meta-analysis , 2016 .

[18]  Principal Consultant,et al.  Guidance on Learning From Incidents, Accidents and Events , 2015 .

[19]  M. Knowles,et al.  The Adult Learner , 2020, The Department Chair.

[20]  Allison Littlejohn,et al.  University and Industry Interaction in Learning From Incidents , 2011 .

[21]  Mike Pedler,et al.  Accessing local knowledge: action learning and organizational learning in Walsall , 2002 .

[22]  Ben J. M. Ale More thinking about process safety indicators , 2009 .

[23]  Rosemary S. Caffarella,et al.  Learning in Adulthood: A Comprehensive Guide, 3rd ed. (San Francisco, CA: John Wiley & Sons/Jossey-Bass, 2007 , 2011 .

[24]  Bettina Berendt,et al.  Learning Analytics and their Application in Technology-enhanced Professional Learning , 2013 .

[25]  Guy H. Walker,et al.  A review of sociotechnical systems theory: a classic concept for new command and control paradigms , 2008 .

[26]  Timothy D. Wilson,et al.  Telling more than we can know: Verbal reports on mental processes. , 1977 .

[27]  J. Logsdon The challenger launch decision: Risky technology, culture, and deviance at NASA , 1997 .

[28]  Marlys K. Christianson,et al.  Managing the unexpected , 2001 .

[29]  Matthias Bergmann,et al.  Methods for Transdisciplinary Research: A Primer for Practice , 2013 .

[30]  A. Onwuegbuzie,et al.  Mixed Methods Research: A Research Paradigm Whose Time Has Come , 2004 .

[31]  Knud Illeris,et al.  The Fundamentals of Workplace Learning: Understanding How People Learn in Working Life , 2010 .

[32]  Guy H. Walker,et al.  Pilot error versus sociotechnical systems failure: a distributed situation awareness analysis of Air France 447 , 2016 .

[33]  Paul E. Spector,et al.  Methodologies for the study of organizational behavior processes: How to find your keys in the dark , 2014, Journal of Organizational Behavior.

[34]  Jean-Luc Wybo,et al.  The case for research into the zero accident vision , 2013 .

[35]  Ingrid Bouwer Utne,et al.  Building Safety indicators: Part 1 – Theoretical foundation , 2011 .

[36]  Evan Heit,et al.  Judgments of learning and improvement , 2010, Memory & cognition.

[37]  Trevor Kletz,et al.  Learning from Accidents , 2001 .

[38]  T. D. Wilson Review of: Ybema, Sierk, Yanow, Dvora, Wels, Harry & Kamsteeg, Frans. Organizational ethnography: studying the complexities of everyday life. Los Angeles, CA: Sage, 2009 , 2011, Inf. Res..

[39]  Anoush Margaryan Work-based Learning: A Blend of Pedagogy and Technology , 2012 .

[40]  Kathryn Mearns,et al.  Safety climate, safety management practice and safety performance in offshore environments , 2003 .

[41]  M. Dixon-Woods,et al.  An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. , 2009, Social science & medicine.

[42]  Linda Drupsteen,et al.  What is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents and Disasters , 2014 .

[43]  Alexander Baumgartner,et al.  Error Climate and How Individuals Deal with Errors in the Workplace , 2014 .

[44]  Betty Collis,et al.  Design criteria for work-based learning: Merrill's First Principles of Instruction expanded , 2005, Br. J. Educ. Technol..

[45]  K. Nowak Teaching self-control: road safety and traffic education in postwar Germany , 2016 .

[46]  Nicholas A. Ashford,et al.  The feasibility of encouraging inherently safer production in industrial firms , 2003 .

[47]  M. Eraut Learning from other people in the workplace , 2007 .

[48]  Allison Littlejohn,et al.  Measuring the Quality of Learning From Incidents Processes in the Workplace , 2013 .

[49]  Roderick E. White,et al.  An Organizational Learning Framework : From Intuition to Institution Author ( s ) : , 2007 .

[50]  Stephen Billett,et al.  Toward a Workplace Pedagogy: Guidance, Participation, and Engagement , 2002 .

[51]  James. F. Halpin Zero defects : a new dimension in quality assurance , 1966 .

[52]  Ashraf Labib,et al.  Learning how to learn from failures:the Fukushima nuclear disaster , 2015 .

[53]  D. L. Simms,et al.  Normal Accidents: Living with High-Risk Technologies , 1986 .

[54]  Bradley R. Staats,et al.  'My Bad!' How Internal Attribution and Ambiguity of Responsibility Affect Learning from Failure , 2014 .

[55]  Marian Iszatt-White Catching them at it , 2007 .

[56]  Allison Littlejohn,et al.  A framework for learning from incidents in the workplace , 2012 .

[57]  Neville A. Stanton,et al.  Why Did the Pilots Shut Down the Wrong Engine? Explaining Errors in Context Using Schema Theory and the Perceptual Cycle Model , 2012 .

[58]  H. C. Blakstad,et al.  Environmental conditions for safety work - Theoretical foundations , 2012 .

[59]  A. Margaryan,et al.  Individual agency in learning from incidents , 2013 .

[60]  Laura Fruhen,et al.  Team cohesion and error culture in risky work environments , 2014 .

[61]  Judith Rainhorn,et al.  A history of the workplace : environment and health at stake , 2014 .

[62]  P. Pintrich,et al.  Motivation in Education: Theory, Research, and Applications , 1995 .

[63]  Where Learning Happens. , 1969 .

[64]  Paul J. Feltovich,et al.  The Cambridge handbook of expertise and expert performance , 2006 .

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

[66]  Petter Grytten Almklov,et al.  Organisational safety indicators: Some conceptual considerations and a supplementary qualitative approach , 2010 .

[67]  A. Margaryan,et al.  Comparing safety culture and learning culture , 2014 .