Key aspects in managing safety when working with multiple contractors: A case study.

Working with multiple contractors in a shared workplace can introduce and increase safety risks due to complexity. The aim of this study was to explore how safety issues are recognized in a specific case and to identify whether clients and contractors perceive problems similarly. The safety issues are explored through a brief survey and a workshop in the maintenance department of a logistics company. The results indicate that culture and behavior are recognized differently by clients and by contractors. The contractors and client had different perceptions of involvement of contractors by the client. The contractors complained on lack of involvement, which was not fully recognized by the client. The case study used a practical approach to show differences in perception of safety within a project. The study illustrates the need for more applied studies and interventions on contractor safety.

Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn.

If organizations would be able to learn more effectively from incidents that occurred in the past, future incidents and consequential injury or damage can be prevented. To improve learning from incidents, this study aimed to identify limiting factors, i.e. the causes of the failure to effectively learn. In seven organizations focus groups were held to discuss factors that according to employees contributed to the failure to learn. By use of a model of the learning from incidents process, the steps, where difficulties for learning arose, became visible, and the causes for these difficulties could be studied. Difficulties were identified in multiple steps of the learning process, but most difficulties became visible when planning actions, which is the phase that bridges the gap from incident investigation to actions for improvement. The main causes for learning difficulties, which were identified by the participants in this study, were tightly related to the learning process, but some indirect causes - or conditions - such as lack of ownership and limitations in expertise were also mentioned. The results illustrate that there are two types of causes for the failure to effectively learn: direct causes and indirect causes, here called conditions. By actively and systematically studying learning, more conditions might be identified and indicators for a successful learning process may be determined. Studying the learning process does, however, require a shift from learning from incidents to learning to learn.

Critical steps in learning from incidents: using learning potential in the process from reporting an incident to accident prevention.

Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.