Learning from accidents : what more do we need to know?

• 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.

Subject headings

HUMANIORA  -- Filosofi, etik och religion -- Filosofi (hsv//swe)

HUMANITIES  -- Philosophy, Ethics and Religion -- Philosophy (hsv//eng)

Keyword

Experience feedback

Accidents

Incidents

Evaluation studies

Accident investigation

CHAIN model

Philosophy subjects

Filosofiämnen

Publication and Content Type

ref (subject category)

art (subject category)