Ep.48 What are the missing links between investigating incidents and learning from incidents?

This discussion is building off last week’s episode where we focused on blame. We thought we would dig a little deeper into how people learn from incidents. 

We use the paper, What is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents, and Disasters, in order to frame our chat.

Topics:

• Single and double-loop learning.
• Incident learning models.
• The least effective method of learning. 
• How to make a safety bulletin effective.
• Why organizational trust is a factor in learning.
• Why management is important to creating a culture of safety.
• Lessons Learned About Lessons Learned Systems.
• Practical takeaways.

Quotes:

“Learning from accidents is pretty much the oldest type of safety work that exists...and almost from the very start, people have been complaining after accidents about people’s failure to learn from previous accidents.”

“This paper really confirms the answer that we gave last week to our question about, ‘does blame sort of get in the way of learning?’ “

“You’ve got to admit that you are wrong now in order to become correct in the future.”

Resources:

What is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents, and Disasters

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