WHAT ARE THE BOTTLENECKS IN THE LEARNING FROM INCIDENTS PROCESS? L. Drupsteen a , D.J.M. Steijger a , J. Groeneweg a,b , G.I.J.M. Zwetsloot a,c a The authors are researchers/consultants at TNO Quality of Life j Work and Employment, Hoofddorp, The Netherlands b Jop Groeneweg is assistant professor at Leiden University, The Netherlands c Gerard Zwetsloot is special professor at the Institute of Work, Health and Organisations, Nottingham University, UK The main purpose of our ongoing study is to develop knowledge on how to improve learning from incidents in organisations. In this phase of the study insight into the main bottlenecks is created. Many organizations investigate accidents and incidents to understand what happened, what caused it and why, and how to learn lessons from them to prevent re-occurrence. No matter how accurate the investigation and analysis are: further steps are necessary to prevent re-occurrence. By learning from incidents, re-occurrence of these incidents and the occurrence of similar events can be prevented and therefore safety performance can be improved. In an earlier phase of the study a model of the learning from incidents process, which is the process from reporting an inci- dent to verifying the effectiveness of remedial measures, is developed. A survey was performed to locate where the main bottlenecks arose. In this paper the types of bottlenecks that hinder the learn- ing from incidents process will be described. INTRODUCTION Preventing and reducing the number of incidents is an important objective of organisations. Many of them have problems in lowering the number of incidents, partly because of inadequate learning from previous incidents (Jones, 1999; Kjelle ´n, 2000; Kletz, 2001, Ko ¨rvers, 2004). In this paper by using the term incidents we refer to all kinds of unwanted deviations or occurrences of the business processes without detailed specification of their conse- quences. They are symptoms of the failure causes and identifying these causes and learning from them can be an important contribution to safe and reliable processes with fewer incidents (van Vuuren, 1998; Reason, 1990; Groeneweg, 1998). Learning from incidents is not only focused on pre- vention of recurrence, but also on improving the learning process and by that the organisations ability to deal with all kinds of deviations to achieve a process of continuous improvement. In order to accomplish that goal it is of great importance to prevent re-occurrence of incidents by taking adequate measures targeted at the root causes and establishing the effectiveness of them. That means that the overall process from the moment an incident emerges up till implementation of interventions on the root causes and evaluating effectiveness, must be improved. To analyse how companies can learn from incidents and where bottlenecks in that learning process can occur, TNO developed an analytical framework (Drupsteen, 2010). This framework enables analysis of the learning from incidents process and consists of eleven steps, divided into four blocks or phases: incident investigation and analysis, planning of interventions, intervening and evaluating. The framework shows that bottlenecks or bar- riers are possible in each phase and in different steps. The first stage is incident investigation and analysis, starting with reporting of an incident and followed by registration of the incident, determining the depth and scope of research, fact finding and incident analysis. This stage results in understanding of the causation. The second stage is called planning of interventions and consists of determining the priority and urgency of actions, formulat- ing recommendations and formulating the action plan, resulting in a realistic action plan. The third stage: interven- ing, results in the realisation of actions, after communicating them to relevant actors and after finding the resources to perform these actions. In the final stage: evaluation, are the implementation process and the effectiveness of the actions evaluated. Each of the four phases leads to a result (gate or a portal) that forms input for the following phase. The result is important, but not sufficient to effectively learn from inci- dents. If results are not obtained, or if they are inadequate, the next phase can still be performed. It is for example poss- ible that recommendations are formulated even without actual understanding of the causation of an incident. In a previous article the steps in the learning from incidents cycles are presented in further detail and the main bottlenecks or barriers are located (Drupsteen, 2010). The results indicated that bottlenecks arise mainly in the verification of the effectiveness and in the evaluation of the process, but some hindrances exist in the reporting of accidents and near misses as well. To resolve the bottle- necks and to improve the learning from incidents process, insight into the bottlenecks is needed. What the barriers and bottlenecks are will be described in this paper. METHODS The information in this study was collected during an online survey with open ended questions and a workshop with 15 safety professionals from a wide range of organisations. These activities are both performed in 2010, as part of the study “learning from incidents”. In this paper bottle- necks in the learning process are presented. All results are qualitative. SYMPOSIUM SERIES NO. 156 Hazards XXII # 2011 IChemE 94