<p>The subject of this licentiate thesis is experience feedback from accidents and incidents. The thesis aims to contribute to an understanding of how the learning processes within organizations, companies and authorities could be improved.</p><p><i>Essay I </i>(written together with Sven Ove Hansson) reports on an evaluation carried out in 2004 by the Swedish Work Environment Authority’s Accident Investigation Board, called HAKO (Haverikommissionen). An important outcome of this evaluation shows that HAKO have not been able to manage the dissemination of their written reports, which is unfortunate, since the reports are thoroughly written.</p><p><i>Essay II</i> (written with Sven Ove Hansson and Carl Rollenhagen) is an overview of the literature on learning from accidents and incidents. The focus in this essay is on literature that evaluates the effectiveness and usefulness of different methods in accident investigations. The conclusions drawn from this literature review are that the dissemination of results and knowledge from accident investigations must be improved, and experience feedback systems should be integrated into overall systems of risk management.</p><p>The starting point for<i> Essay III </i>was an empirical study conducted in 2005/2006. Twenty-eight supervision cases from eleven local Environment and Health Administrations in Sweden were examined. The overall goal of the study was to find out how, and to what extent, experience feedback occurs between different municipal authorities. Two major problems affecting experience feedback have been found; namely, that the inspectors do not have enough guidance on how to interpret the law, and that they would like more information on what happens to legal cases they have reported to public prosecutors and police.</p>

The subject of this licentiate thesis is experience feedback from accidents and incidents. The thesis aims to contribute to an understanding of how the learning processes within organizations, companies and authorities could be improved. Essay I (written together with Sven Ove Hansson) reports on an evaluation carried out in 2004 by the Swedish Work Environment Authority’s Accident Investigation Board, called HAKO (Haverikommissionen). An important outcome of this evaluation shows that HAKO have not been able to manage the dissemination of their written reports, which is unfortunate, since the reports are thoroughly written. Essay II (written with Sven Ove Hansson and Carl Rollenhagen) is an overview of the literature on learning from accidents and incidents. The focus in this essay is on literature that evaluates the effectiveness and usefulness of different methods in accident investigations. The conclusions drawn from this literature review are that the dissemination of results and knowledge from accident investigations must be improved, and experience feedback systems should be integrated into overall systems of risk management. The starting point for Essay III was an empirical study conducted in 2005/2006. Twenty-eight supervision cases from eleven local Environment and Health Administrations in Sweden were examined. The overall goal of the study was to find out how, and to what extent, experience feedback occurs between different municipal authorities. Two major problems affecting experience feedback have been found; namely, that the inspectors do not have enough guidance on how to interpret the law, and that they would like more information on what happens to legal cases they have reported to public prosecutors and police. / QC 20101118

Bridge Navigational Watch Alarm System (BNWAS) blev implementerat i the International Convention for the Safety Of Life At Sea (SOLAS) år 2009. Sedan dess har olika typer av fartyg haft längre eller kortare tid på sig att installera systemet ombord. Navigatörer har utryckt både positiva och negativa synpunkter på systemet. Syftet med studien var att få en uppfattning om hur implementeringen av BNWAS har utvecklats praktiskt inom sjöfarten. För att undersöka detta har haverirapporter granskats innan samt efter implementeringen. Resultatet från detta har jämförts med tidigare implementeringar inom samma område. Data har sedan kvantitativt och kvalitativt analyserats. Resultaten tyder på att implementeringen av BNWAS har stött på samma problem som liknande implementeringar gjort tidigare. De slutsatser som dragits utifrån dessa resultat var att implementeringen av BNWAS kunde ha gjorts på ett bättre sätt om lärdomar från tidigare implementeringar tagits med i utvecklingen av implementeringen. Studien visade att grundstötningar har minskat i den undersökta haverikommissionens utredningar. / BNWAS was implemented in SOLAS, chapter V in 2009. Since that year, different types of ships have had different time schedules to install the system onboard. Navigational watch keepers have expressed both positive and negative attitudes towards the system and the operation of it. The purpose was to shed light upon how the implementetion of BNWAS has developed practically at the end users. The purpose of the study has been fulfilled through both qualitative and quantitative methods. Accident investigation reports both before and after the implementation were examined togheter with examinations and reviews of earlier studies regarding questions about implementation. This work was done to reach the goal of the study with a reliable result. These results implied that the implementation had encountered the same problems as earlier implementations (in the same area) had. They also showed that groundings of ships occured in the same way both before and after the implementation. The conclusions was that the implementation of BNWAS could have been developed more smoothly if the problems from earlier implementations had been accounted for. The groundings have however been reduced significantly since the implementation, whether it is due to the implementation or something else is still to be found out with a more comprehensive study.

This paper carry out a qualitative meta-analysis of 112 “proposals for action” identified in 30 of the approximately 630 accident investigations that are published on the Swedish Civil Contingencies Agency (MSB) website. Accident investigations have been carried out at the discretion of each municipality and then sent to the MSB, which in turn, after a secrecy review and an ethical review, publishes most of the investigations on the web page Kommunala olycksundersökningar. The accident investigations are split into a number of different categories by type of event and the categories analysed in this paper are “Automatic alarm - not fire” and “Fire - not in building”.The process of learning from accidents can be illustrated using the CHAIN model (Reporting - selection - Investigation - spread - implementation). This model attempts to show how the process of learning from accidents step by step and point out that every step must be followed and implemented for a lesson to be learned - from event to implemented lesson learned. Previous studies however have found that the steps in the CHAIN model are not followed from the beginning to the end in terms of learning from municipal accident investigations. A first problem is that some proposals listed can be unclearly formulated in terms of who is supposed to carry out the proposal, but above all, there are weaknesses in distribution and thus also the implementation of the proposals.Aim and method This paper seeks to compile, analyse and present the proposals for action contained in the selected accident investigations. The method used is a qualitative meta-analysis understood here as an "analysis of analyses" performed with the qualitative method content analysis, which may also contain quantitative elements.Findings Almost all of the proposals set out are alone in its kind. There is just two proposals contained more than once. Proposals for measures can be further divided into categories by thought, or stated, receivers and for similarities between the proposals. More than half of all proposals are targeted to Rescue services own work, either regarding the intervention itself, organizational or other planning or collaboration with other agencies or stakeholders. One group is aimed towards the operator and propose improvements in various parts of their systematic fire prevention (SBA). Two smaller groups of proposals suggests improvements for handling errors and to do changes in the products and that this information should be communicated to operators/retailers or producer. Some proposals do not fall within any of the other categories.It noted that, in principle, all suggestions are workable and implementable and that these proposals can be generalized beyond its original context into a larger one. And that this kind of qualitative meta-analysis can be a part of the CHAIN model's implementation. / I denna uppsats görs en kvalitativ metaanalys av 112 förslag på åtgärder vilka anges i 30 av de runt 630 kommunala olycksundersökningar som finns publicerade på Myndigheten för samhällsskydd och beredskaps (MSB) hemsida. Olycksundersökningarna har genomförts efter beslut i respektive kommun och därefter skickats in till MSB, vilka i sin tur, efter en sekretessprövning och en etisk prövning, publicerar de flesta på webbsidan Kommunala olycksundersökningar. Olycksundersökningarna delas upp på ett antal olika kategorier efter typ av händelse och de kategorier vilka analyseras i denna uppsats är Automatlarm – ej brand samt Brand – ej i byggnad.Processen att lära från olyckor kan åskådliggöras med hjälp av CHAIN-modellen (rapportering – urval – utredning – spridning – genomförande). Denna modell vill visa på hur processen med lärandet från olyckor går till steg för steg samt poängtera att varje steg måste följas och genomföras för att ett lärande ska komma i mål – från händelse till implementerad lärdom. Tidigare studier har dock funnit att CHAIN-modellens steg inte följs från början till slut vad gäller lärandet från kommunala olycksundersökningar. Ett första problem är att vissa förslag som anges kan vara otydligt formulerade vad gäller vem som ska genomföra förslaget, men framförallt finns det brister i spridningen och således också genomförandet av förslagen.Syfte och metod Denna uppsats syfte är att sammanställa, analysera och presentera de förslag på åtgärder som återfinns i de utvalda olycksundersökningarna, samt att värdera dessa utifrån generaliserbarhet. Metoden som använts är en kvalitativ metaanalys med vilket här avses en ”analys av analyser” utförd med den kvalitativa metoden innehållsanalys, vilken också kan innehålla kvantitativa inslag.Resultat Nästan alla de förslag på åtgärder som anges i olycksundersökningarna är ensamma i sitt slag, det är bara 2 förslag som återfinns mer än en gång. Detta beror troligen på att en utökad olycksundersökning görs först om utredningen bedöms kunna tillföra ny information. Förslagen på åtgärder kan vidare delas in i kategorier efter tänkt, eller angiven, mottagare samt efter likheter mellan förslagen. Men än hälften av alla förslag är riktade mot Räddningstjänstens eget arbete, antingen gällande själva insatsen, organisatoriskt eller annat planeringsarbete eller gällande samverkan med andra myndigheter eller aktörer. En grupp förslag riktar sig mot verksamhetsutövaren och föreslår förbättringar i olika delar av dessas Systematiska brandskyddsarbete. Två mindre grupper förslag ger förslag på förbättringar efter handhavandefel respektive på förändringar av produkter samt att denna information ska delges verksamhetsutövare/återförsäljare eller producent. Några förslag faller inte inom någon utav de övriga kategorierna.Konstateras görs också att i princip alla förslag är konkreta och genomförbara samt att dessa förslag kan generaliseras utanför sitt ursprungliga sammanhang till en större kontext. Samt att denna typ av kvalitativ metaanalys kan vara ett led i CHAIN-modellens genomförande.