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OECD
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Better Cross Sector Learning from Accidents a
Necessity for Coping with To-morrows Risks
Presentation at the First Nordic Conference on
Emerging Risks and Regional Economic Development
Karlskoga 24 - 25 November 2003 by Thomas
Gell Swedish National Centre for Lessons Learned
from Accidents Swedish Rescue Services
Agency email thomas.gell_at_srv.se

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A Learning Challenge

• Fast pace of technological change
• New types of hazards
• Increasing complexity and coupling
• Changing regulation
• Decreasing tolerance

Learn quicker Learn new Learn together More must
learn Learn better


Conclusion A very proactive and foresighted
learning needed Learning from past experiences
is not enough

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But, first things first

• For the most basic learning task to learn from
  what has happened, and happens, we are not in the
  neighbourhood of being good enough.

• All dynamic systems, e.g. our socio-technical
  society, need monitoring and feedback loops.

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The Accident Bow-Tie


Normal Conds
Normal Conds

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Learning tasks

Learning tasks To collect data from all
phases/perspectives, analyse it and dissiminate
knowledge/lessons learned in order to

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Differing Scales and Perspectives

• Drowning
• Fires
• Carcrashes

Frequency

• Dam failures/floods
• Train/Ship
• Dangerous goods

Common Unusual Rare

• Nuclear
• Epidemic
• Global warming

individual group society
Consequence impact

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A Systemic Risk in Fagerås?
Fall är den vanligaste olycksorsaken
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Can a simple paper-container be a systemic risk?
The Silence is total A Year ago, their two
sons, Christopher och Alexander, were compressed
to death in a container for used paper NORBERG.
Skolväskorna hänger där på sin stolpe.
Anteckningarna och leksakerna ligger framme.Som
om de skulle komma hem igen, vilket ögonblick som
helst. Det har gått ett år sedan Christopher och
Alexander dog i containern. Bröderna Christopher,
9, och Alexander, 6, klättrade in och lekte i en
container för returpapper. Plötsligt kom
lastbilen för att tömma containern. Pojkarna
klämdes till döds. (Aftonbladet 19 april 1998)
Fall är den vanligaste olycksorsaken
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Container contd

• Quick fix

Fall är den vanligaste olycksorsaken
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Conclusions

• New application - limited experience
• Narrow risk analysis
• Rapid mass deployment
• Unclear Responsibilities
• No feed-back system
• Poor management
• Lack of safety culture

• Dread risk gt Zero tolerance

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The Socio-technicalSystem

• Steering signals
• Laws
• Regulations
• Management Policies
• Plans

• Feed-back signals
• Accident Analyses
• Incident reports
• Data

Adopted from RassmussenSvedung

Hazardous physical process
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Structural Obstacles to the Learning Process 1/



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Structural Obstacles to the Learning Process 2/


Most of existing Information systems for lessons
learnt are designed from a top-down perspective.
Motivation for reporting and learning at the
grass-root practical level is not stimulated.

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Structural Obstacles to the Learning Process 3/




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Need for Cross Sector Co-operation

• A better conceptual framework development of a
  taxonomy

• Data collection/compatibility/distribution

• Exchange of accident Information using networks
  instead of hierachical Systems

• Dissemination of lessons learnt the problem of
  information overflow

• The use of lessons learnt in decision making and
  education

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Need for Cross Sector Co-operation

• Blame versus learning questions of safety culture

• Systemic accident investigation methodologies

• Early warning Capability to react on vague
  indicators

Enhance multidisciplinarity in risk assessment
and management Detect changes in the risk
landscape early Exchange information and share
best practices among sectors Develop safety
culture through education, training and
communication Build effective surveillance, to
provide decision makers with usable
information Create partnerships to alleviate the
costs in risk reduction