Underlying causes and level of learning from accidents reported to the MARS database

Jacobsson, Anders; Sales, Jaime; Mushtaq, Fesil

doi:10.1016/j.jlp.2009.05.002

Cited by 27 publications

(16 citation statements)

References 1 publication

(4 reference statements)

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“…When analyzing incidents in the process industries one will from a practical view normally find that many of the lessons learned concern only the most immediate vicinity within a plant where the incident occurred (Jacobsson, Sales, & Mushtaq, 2010). Occasionally, the lesson learned will be applied on a much broader geographical scale.…”

Section: Level Of Learning and Type Of Learningmentioning

confidence: 99%

“…The method of evaluating the actual level of learning from incidents is based on a previously presented model used to evaluate learning from accidents reported to the MARS (Major Accident Reporting System) database for major accidents under the Seveso legislation (Jacobsson et al, 2010). This method is in turn based on a system originally developed by Van Court Hare (1967) and refined by Kjellén (2000).…”

Section: Step 1: Actual Learningmentioning

confidence: 99%

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Method for evaluating learning from incidents using the idea of “level of learning”

Jacobsson

Akselsson

2011

Journal of Loss Prevention in the Process Industries

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Section: Level Of Learning and Type Of Learningmentioning

confidence: 99%

Section: Step 1: Actual Learningmentioning

confidence: 99%

Method for evaluating learning from incidents using the idea of “level of learning”

Jacobsson

Akselsson

2011

Journal of Loss Prevention in the Process Industries

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“…In safety critical domains, such as process control, aviation and healthcare, a number of sector-wide systems have existed since the early 1980s and 2000s (e.g., the Major Accidents Reporting System, 2012; Aviation Safety Reporting System, 2015; and the U.K.'s National Health Service Patient Safety reporting system, Department of Health, 2006). These sector-wide systems are intended to support cross-organizational learning from incidents, as well as reforms to regulation and legislation (Vincent, 2004; Jacobsson et al, 2010; Lindberg et al, 2010). Concerns have been raised, however, that there is little evidence that incident data is actually used to identify prevention strategies or support learning from incidents (Nielsen et al, 2006; Pless, 2008; Jacobsson et al, 2010; Lindberg et al, 2010).…”

Section: Introductionmentioning

confidence: 99%

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

et al. 2016

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Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

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“…Among the basic causes of high accident rate is poor learning from accident (Jacobsson et al, 2010). According to (Lindberg and Hansson, 2006) the weakest link of feedback based on experience in the process learning cycle is related to dissemination of accident information.…”

Section: Introductionmentioning

confidence: 99%

Method for identifying errors in chemical process development and design base on accidents knowledge

Kidam

Sahak

Hassim

et al. 2015

Process Safety and Environmental Protection

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Underlying causes and level of learning from accidents reported to the MARS database

Cited by 27 publications

References 1 publication

Method for evaluating learning from incidents using the idea of “level of learning”

Method for evaluating learning from incidents using the idea of “level of learning”

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

Method for identifying errors in chemical process development and design base on accidents knowledge

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