Systemic Approach to Improve Learning from Incidents
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Learning from incidents has always been very challenging for industry and regulators due to the associated complexity in human and organizational behavior. In spite of the efforts and resources spent on incident investigation processes and organizational learning techniques, the outcome has not shown a significant improvement. Chemical process incidents such as Texas City Refinery explosion, T2 Laboratories explosion, and West Fertilizer explosion continue to occur. It is evident that as an industry, organizations are continually failing to learn from the past incidents. The question is if organizations are ready to learn, are they following the right learning approach? Organizations should adopt a systemic learning approach where the collected knowledge is leveraged in order to enhance the performance of the safety management systems and consequently prevent future incidents. The objective of this research is set to enhance our understanding on how a company and the industry as a whole learn from past incidents and define the key elements to improve the systemic learning. This study was divided into four main phases: identification of the learning system, development of a learning process and a proposed incident investigation process and finally the validation of the proposed incident investigation process through a case study. First, the learning system for the chemical and oil and gas industry, the different types of learning, and the entities involved in it has been characterized. Based on the results, some limitations on the system were identified and discussed. Secondly, a systemic process for improving learning from incidents has been developed based on the identified limitations of the learning system. The proposed process provides a holistic view of the learning process and explored the concept of knowledge management into safety systems. Likewise, it provides guidelines of how learning systems can be executed within the organization and how to support the implementation of safety knowledge inside of it. Third, an incident investigation process has been proposed to provide additional sources of information into the analysis, in order to support the identification of root causes and the required changes in the management systems of the organization. The process that has been developed enhances understanding of how to get information and transform it into valuable recommendations that can be implemented in their processes. Finally, the proposed process has been explained through a case study. The obtained results provide a clear picture of how an incident investigation report can be enhanced through this process.
SubjectLearning from incidents
learning from experience
incident investigation process
Guarguati Ariza, Juliana Andrea (2017). Systemic Approach to Improve Learning from Incidents. Master's thesis, Texas A & M University. Available electronically from