Focus

Why do we find it so hard to learn lessons from incidents and accidents?

December 2014

For years now in my work as an occupational safety and health information specialist I have handle thousands of documents, articles from magazines, reports and papers presented at conferences and talked with and listened to people, including inspectors worldwide and have constantly wondered why we never seem to learn lessons from incidents and accidents in the workplace.

I also believe that we should start really early in the education system and teach children about workplace accidents. Children are taught about road safety and swimming safely successfully. So are we missing something?

A recent review from the UK Emergency Planning College entitled Learning the Lessons from Major Incidents: A Short Review of the Literature, by Eve Coles Visiting Fellow in Civil Protection looks at some of the questions. This short review of the literature on organisational learning from crises and emergencies has been commissioned by the Cabinet Office Civil Contingencies Secretariat to support the ongoing work being undertaken by the Joint Emergency Services Interoperability Programme (JESIP). It is not a definitive review of all the literature in the area but simply an indication of what the current research is saying with regard to the universal problem of “learning the lessons”. Nevertheless many documents have been read, ranging from doctrine and guidelines to research papers (57 of which are referenced in this paper) in an attempt to identify why it is that we continually fail to convert “lessons identified” from emergency response into embedded “lessons learned”.

Consideration was given to how learning may or may not take place at a macro (national or state) level, an organisational level and an individual level, and it became increasingly apparent during the preparation of this paper that this is a complex area of interdisciplinary theory and research that draws on many different fields.

Consequently the review is structured thematically, closely following those themes that have emerged as the literature was surveyed. These are:

Introduction: back ground to the research and the problem of learning lessons from major emergencies
Turning lessons identified into new policy and doctrine: Policy learning and change at the macro (national or state) level
Organisational learning from crises and emergencies: problems and issues associated with learning at the organisational level and the significance of single loop and double loop learning
Information management and sharing: issues associated with the dissemination of information and learning from emergency response at an intra-organisational level and an inter-organisational level
Why we find it so hard to learn the lessons of experience
Individual learning: a review of some barriers to individual learning and the meta-cognitive skills needed to ensure the learning of lessons
Team learning: Development of team knowledge and the issues raised for ad hoc multi-agency teams in emergency response
Culture and organisational learning and change: the importance of organisational culture and change management with regard to learning lessons
Conclusions and recommendations: drawing together the themes of the review and proposed further work
References: list of sources cited in the review

Learning the Lessons from Major Incidents: A Short Review of the Literature
Eve Coles, Visiting Fellow in Civil Protection, Emergency Planning College
www.epcollege.com/EPC/media/MediaLibrary/Knowledge%20Hub%20Documents/J%20Thinkpieces/Occ10-Paper.pdf

Also in OSH UPDATE + FIRE www.oshupdate.com which has over 1,112,000 records including over 91,200 full text documents.