Accident investigation and learning (NFR)

The major goal of this project has been to reveal different patterns in the learning processes from accident investigations. We are interested in the very construction of and change in learning processes. We also want to analyse how these learning processes are dependent on their specific societal contexts. So far we have explored different sectors, such as the transport sector, the emergency response sector and we are now starting up a project in petrochemical sector (refineries). We have also studied specific major accidents in other sectors and we have carried out a historic analysis of the development of the Norwegian and Swedish accident investigation committees/boards and looked at structural premises of the different accident investigation boards related to transport in Scandinavia.

The projects have tried to test the main hypothesis that accident investigations play an insignificant role in the learning at individual, organizational and cross sectoral levels in society. This hypothesis presupposes 4 sub-hypotheses:

  • The learning perspective of accident investigation is poorly founded. The learning effects are minor, especially for actors not directly involved in the accident.
  • Accident investigation reports only infer changes and learning when governments instruct changes to regulations.
  • Accident investigation results are often fronted in political populist cases, which usually “fall to the ground” without long term results.
  • The performance of the rescue and combat resources are seldom evaluated in accident investigations, and thus there is no tradition for criticism of the external (often public) emergency management which influences learning besides those directly involved.

By no means no final conclusions are yet made, but through single cases we have explored learning and found that the investigations it selves are less important as an educational tool. The project has involved many collaborating parties; Lund University, IRIS, Sintef, Norwegian Board of Health Supervision, Accident Investigation Board Norway and Directorate for Civil Protection and Emergency Planning.

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