| 1. |
- Lindberg, Anna-Karin
(författare)
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Learning from accidents : Experience feedback in practice
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Experience feedback from accidents is important for preventive work in companies, authorities and other organisations. This thesis focused on experience feedback from accidents that take place in everyday life, in our neighbourhoods, in our workplaces, in our schools, in traffic and transportation. Essay I is an overview of the literature on learning from accidents and incidents. The focus in this essay is on literature that evaluates the effectiveness and usefulness of different methods in accident investigations. Conclusions drawn from this literature review are that the dissemination of results and knowledge from accident investigations must be improved, and experience feedback systems should be integrated into overall systems of risk management. Essay II is based on an evaluation of the investigation board for workplace accidents (HAKO) that was carried out on commission of the Swedish Work Environment Authority. It was concluded that the accident reports published by HAKO had a high qualitative level but the dissemination of results from the investigations was weak. Essay III investigates twenty-eight supervision cases from eleven Swedish local Environment and Health Administrations. The overall goal of the study was to find out how, and to what extent, experience feedback occurs in Swedish municipalities. Two major problems relevant for the experience feedback have been found; namely that the inspectors do not have enough guidance on how to interpret the law and that they would like more information on what happens to legal cases that they have handed over to the public prosecutors and the police. Essay IV is a document study of incident reports from two municipal fire and rescue services. The overall purpose of this study was to investigate if information from the rescue services could be used to improve experience feedback in sectors where it is weak or non-existent. In the 1120 incident reports that were studied, we found 217 proposals for improvement but these proposals were not used for experience feedback. It is concluded that the reports contain valuable information but this information is not used to prevent future accidents. Essay V investigates experience feedback in Swedish authorities working with accident prevention. The essay is based on two interview studies. In the first study, 21 Swedish authorities participated, and several of these authorities seem to have a functioning experience feedback despite the lack of systematic routines and methods. Yet, only four of the 21 authorities actually handle the whole experience feedback process. These four have at least one common denominator; they have an experience feedback that is turning more inwards than outwards. The second study was a follow-up study of some of the results from the first study, concerning the dissemination of results from experience feedback.
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| 2. |
- Lindberg, Anna-Karin, et al.
(författare)
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Learning from accidents : what more do we need to know?
- 2010
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 48:6, s. 714-721
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Tidskriftsartikel (refereegranskat)abstract
- A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.
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| 3. |
- Lindberg, Anna-Karin, 1977-
(författare)
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Räddningstjänstens insatsrapporter : En studie av erfarenhetsåterföring i kommunal räddningstjänst
- 2009
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Rapport (populärvet., debatt m.m.)abstract
- The 204 Swedish municipal rescue services carry through about 90 000 rescue turnouts per year. Every turnout is documented in a turnout report form. This study will show what can be learnt from municipal rescue services turnout reports. The main purpose of the study is to investigate how to improve and make experience feedback more effective in municipal rescue services. An underlying purpose is to examine what can be learnt about experience feedback with the turnout reports as point of departure. Experience feedback is a process which starts with the reporting of an accident or incident, and if it is necessary a selection procedure. The accident or incident is investigated and results from the investigation are disseminated. Finally preventive measures are taken. Two municipal rescue services provided the turnout reports. 1122 reports from turnouts carried through in 2006 were studied. The reports have been thoroughly read, divided into categories and analysed. The 215 improvement proposals found in the reports were especially examined and receivers for all proposals were identified. The CHAIN model has been used as a tool to study feedback processes from accident to prevention. It has become clear that the reporting of accidents is working properly and that selection of accidents in need of investigation is not relevant. The investigation procedure for accidents ending up in turnout reports needs some improvement since the quality of many reports is deficient. The dissemination of knowledge from the reports is in great need of improvement. Several improvement proposals were found in the reports but the proposals were not disseminated to people in organisations that can take precautionary measures. Receivers for all proposals can easily be identified in the reports but this needs to be systematized. The municipal rescue services reports are in their present shape an excellent foundation for statistics. However, with rather simple means their application field can be more effective and perhaps also become accident preventive.
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| 4. |
- Lindberg, Anna-Karin
(författare)
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Experience feedback in practice
- 2008
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The subject of this licentiate thesis is experience feedback from accidents and incidents. The thesis aims to contribute to an understanding of how the learning processes within organizations, companies and authorities could be improved. Essay I (written together with Sven Ove Hansson) reports on an evaluation carried out in 2004 by the Swedish Work Environment Authority’s Accident Investigation Board, called HAKO (Haverikommissionen). An important outcome of this evaluation shows that HAKO have not been able to manage the dissemination of their written reports, which is unfortunate, since the reports are thoroughly written. Essay II (written with Sven Ove Hansson and Carl Rollenhagen) is an overview of the literature on learning from accidents and incidents. The focus in this essay is on literature that evaluates the effectiveness and usefulness of different methods in accident investigations. The conclusions drawn from this literature review are that the dissemination of results and knowledge from accident investigations must be improved, and experience feedback systems should be integrated into overall systems of risk management. The starting point for Essay III was an empirical study conducted in 2005/2006. Twenty-eight supervision cases from eleven local Environment and Health Administrations in Sweden were examined. The overall goal of the study was to find out how, and to what extent, experience feedback occurs between different municipal authorities. Two major problems affecting experience feedback have been found; namely, that the inspectors do not have enough guidance on how to interpret the law, and that they would like more information on what happens to legal cases they have reported to public prosecutors and police.
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| 5. |
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| 6. |
- Lindberg, Anna-Karin
(författare)
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Att lära av inspektörers erfarenheter : En undersökning av inspektionsverksamheten i elva kommuner
- 2006
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- Med syfte att undersöka hur erfarenheter från tillsynsärenden tas om hand inom kommunal miljötillsyn samt att se över hur tillsynsarbetet fungerar har 28 tillsynsärenden från elva kommuner studerats. Vid urvalet av kommuner har viss hänsyn tagits till Sveriges Kommuner och Landstings kommungruppering samt till kommunernas geografiska läge. De elva utvalda kommunernas miljökontor har kontaktats och ombetts välja ut exempel på tillsynsärenden med allvarliga missförhållanden och andra intressanta ärenden. Varje ärende har sammanfattats med hjälp av dokumentation som kommunerna har försett oss med. Intervjuer har också genomförts med någon i varje ärende insatt person. Samtal har även förts med andra inblandade.Genomgången av ärendena har visat på att en viktig fråga för inspektörerna när det gäller erfarenhetsåterföring är de juridiska spörsmålen. Det har bland annat framförts att inspektörerna vill ha mer återkoppling från rättsväsendet. Miljönämnderna är enligt 26 kap. 2 § miljöbalken skyldiga att anmäla överträdelser av balken. Åklagarna lägger ofta ner förundersökningar i miljöärenden utan att miljökontoren får någon förklaring till varför. Inspektörerna vill också bli informerade om vad som händer med utdömda viten.En viktig aspekt som undersökningen har påvisat när det gäller erfarenhetsåterföring är betydelsen av fungerande samarbeten. De samarbetsformer som främst nämns av inspektörerna är de regionala. Centrala myndigheters betydelse förefaller bli allt mindre. Det har även framkommit exempel på områden där ytterligare erfarenhetsåterföring är att önska.
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| 7. |
- Lindberg, Anna-Karin, et al.
(författare)
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Evaluating the effectiveness of an investigation board for workplace accidents
- 2006
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Ingår i: Policy and Practice in Health and Safety. - 1477-3996 .- 1477-4003. ; 4:1, s. 63-79
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- This paper examines the activities of the Swedish Work Environment Authority's Accident Investigation Board. It first gives an outline of the board's role and a summary of the previous literature on accident investigation. It then proposes an investigation methodology, the CHAIN model, which forms the theoretical point of departure of the paper. It describes the methods used in the empirical study, and examines the board's investigation criteria and how these were implemented. A summary of the effects of the board's reports on affected companies is presented, along with a survey of SWEA inspectors and interviews with workplace inspectors and others who have an interest in workplace accident investigation. Finally, the study's results are compared to the CHAIN model, with the conclusions that: • the board has been successful in establishing a high qualitative standard for investigating workplace accidents • the investigation process should be speeded up if the board's reports are to realise their full potential • dissemination of the reports must be improved, and a follow-up system is needed.
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| 8. |
- Lindberg, Anna-Karin
(författare)
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Accident prevention through experience feedback from the rescue services : A study of incident reports in Sweden
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- The fire and rescue services are called to the scene of almost all serious accidents. The purpose of this investigation was to find out whether the information they obtain in the course of their normal operations can be used to improve experience feedback in sectors where it is at present weak or non-existent. 1120 incident reports from two local Swedish fire and rescue services were studied. These reports contained 217 proposals for improvement. However, the reports are primarily intended for statistical purposes, and they are currently not used for experience feedback. A system for dissemination of such information is proposed. It is suggested that the rescue services are best equipped to transmit the relevant information to local recipients. A national authority can be entrusted with task to the review and collate information intended for non-local recipients such as companies whose products have been involved in accident and regulatory authorities whose safety regulations may need to be reassessed in light of the experiences reported.
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| 9. |
- Lindberg, Anna-Karin, et al.
(författare)
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Investigating experience feedback in Swedish authorities : An empirical study of experience feedback practice in 21 Swedish authorities
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- This article focuses on practical experience feedback. Results from two interview studies are reported. In the first, experience feedback in different sectors in Sweden was investigated through interviews with 21 Swedish authorities involved in accident prevention. A result from this investigation was that the participating authorities in practice have a functioning experience feedback despite lack of systematic routines and methods. Yet, only four of the 21 participating authorities work with the whole experience feedback process. These four authorities have one common denominator; they have an experience feedback that is turning more inwards than outwards. All of the participating authorities have a need to improve and systematize the dissemination of experiences, knowledge and results. An improved dissemination can in fact affect other procedures such as the reporting of occurred accidents. Focus in this second study was on practical communication procedures, and how the authorities communicate results, knowledge and experiences within their own organisations, with other authorities, and with external parties. It is concluded that a more proactive approach would be valuable for the learning process.
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| 10. |
- Lindberg, Anna-Karin
(författare)
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Learning from Experience in Municipal Environmental Supervision : A study of twenty-six Swedish supervion cases
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Twenty-six supervision cases from eleven Swedish municipal Environment and Health Administrations were examined. This was made in order to determine how and to what extent experience feedback and other exchange of experiences take place among municipal environment authorities and to identify unfulfilled demands of such communication. There was a remarkable lack of demand for classical experience feedback in which information from technological and organizational failures was used to avoid a repetition of the same type of failure. Instead, inspectors expressed a need for exchanges from other agencies dealing with similar issues and a need for systematic feedback from public prosecutors of cases that have been handed over to them.
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