Biases in incident reporting databases: an empirical study in the chemical process industry

Schaaf, TW Tjerk; Kanse, Lisette

doi:10.1016/s0925-7535(03)00023-7

Cited by 102 publications

(34 citation statements)

References 11 publications

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“…Several models are described that represent LFI as a stepwise process (Drupsteen, Groeneweg, & Zwetsloot, 2013;Jacobsson, Ek, & Akselsson, 2011;Lindberg et al, 2010;van der Schaaf, 1992). These models follow similar steps and phases, the first steps of which are aimed at the process of learning lessons, as described in the previous section.…”

Section: Stepwise Learning From Incidents Processesmentioning

confidence: 99%

“…In the literature on LFI, the storing of incident information and lessons learned is not addressed specifically. However, incident registration databases are one example of storing lessons, as is described for instance in papers of van der Schaaf and Kanse (2004) and by Sepeda (2006). Another example is the storing of lessons in regulations and procedures.…”

Section: Sharing Lessons Learnedmentioning

confidence: 99%

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

Drupsteen

Guldenmund

2014

Contingencies & Crisis Mgmt

110

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Learning from incidents, accidents and disasters contributes to improvement of safety and the prevention of unwanted events. In this review, literature on learning from safety incidents within organizations is studied and compared with the organizational learning theory of Argyris and Schön. Sub‐processes, such as learning lessons, sharing, storing and applying lessons, are described, and factors that influence these processes are listed, such as trust, the severity of the consequences of an incident and the people involved in learning. In comparison with the theory of Argyris and Schön, aspects about the information to learn from, i.e., the incident and analysis, are much more specified in the safety literature. However, the organizational learning theory gives more details about the earlier mentioned sub‐processes.

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Section: Stepwise Learning From Incidents Processesmentioning

confidence: 99%

Section: Sharing Lessons Learnedmentioning

confidence: 99%

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

Drupsteen

Guldenmund

2014

Contingencies & Crisis Mgmt

110

View full text Add to dashboard Cite

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“…Instead, it identifies concrete behaviors and environmental conditions that can form the basis of directed interventions. That distinction between mental states and observable behavior has been identified at length in empirical studies about improving engineering safety by understanding how operators truly use their equipment instead of how human factors experts believe they should (Collins 2007, Roberts, et al 1980, Van der Schaaf and Kanse 2004.…”

Section: Findings and Implicationsmentioning

confidence: 99%

4.2.3 Cultural Differences in Systems Engineering: What They Are, What They Aren't, and How to Measure Them

Collins

Callahan²

2009

INCOSE International Symp

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Despite frequent use of the term culture in contemporary engineering practice, there is currently no reliable way of understanding what constitutes true shared beliefs and meanings that impact how groups of Systems Engineers spread across multiple departments and countries work together. This paper develops a framework to address that gap and measure cultural variation in Systems Engineering contexts. Drawing from the field of cultural anthropology, we demonstrate methods to empirically measure cultural consensus and divergence related to fostering collaboration, understanding business success or failure, and identifying characteristics of effective cross-functional teams. The discussion identifies substantive content of what real organizational cultures are, where they are different, and where they overlap. That quantified content feeds culture as a rigorous element of organizational strategy into global alignment and process excellence or six sigma initiatives targeted at changing team behavior. The result is a framework for conducting rigorous, empirical investigations to truly understand the human dimensions that are critical to effective Systems Engineering practice. We discuss areas this approach applies to global process alignment and team effectiveness.

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“…(Vaughan 2004) suggests that elaborate and formal technologies of control do not inherently guarantee accurate risk assessment and communication. (Van der Schaaf and Kanse 2004) distinguish between Kwak and LaPlace's system focused risk identification system and a user focused risk identification system identified among the chemical plant operators. They identify five reasons not to report mistakes based on diary records of self-made errors by chemical plant operators: no remaining consequences after the recovery, recovery rendered the event superfluous to report, not applicable for aims of the reporting database, and other.…”

Section: Organizational Cognition and Risk Controlmentioning

confidence: 99%

7.5.3 Cultural Models of Organizational Risk in Product Development

Collins

2007

INCOSE International Symp

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Abstract. This paper uses cognitive domain elicitation methods to explore taxonomies of risk in engineering product development. The paper places typical technologies of risk control within a context of theories that emphasize system-focused risk identification. Two case studies identify weaknesses in this approach: operator errors in a chemical plant, and pilot error classification on P-3 aircraft. Shifting the emphasis to user-focused rather than system-focused risk identification reveals several key concepts that are missing from the formal theories of risk mitigation. Using numerical analysis from a survey at a small engineering company, the paper explores cognitive anthropology insights regarding the distinction between folk and scientific taxonomies. The results present four significant findings: People who think they disagree with each other don't; experts and non-experts view risky things differently; despite this difference, non-experts have a systematic understanding of risky things; and there are verifiable ways to elicit the structure of this understanding.

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Biases in incident reporting databases: an empirical study in the chemical process industry

Abstract: Abstract

Cited by 102 publications

References 11 publications

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

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

4.2.3 Cultural Differences in Systems Engineering: What They Are, What They Aren't, and How to Measure Them

7.5.3 Cultural Models of Organizational Risk in Product Development

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