This is a multi-authored volume addressing the topical subjects of
event analysis and the learning organisation within the context of
safety management systems.
When an accident occurs, we respond in a number of ways: we look
for someone to blame, we try to understand why it happened, we seek
to learn and take precautions for the future and we may breathe a
sigh of relief and try to forget the accident as quickly as
possible.
This book is about how to manage these various responses to an
accident. It addresses the question of how to manage the stages of
learning from disasters and other accidents and of:
- how data could be collected and analysed to derive the
lessons
- how and how far the different and conflicting objectives of
judicial procedures and organisational learning could be
reconciled.
In the past decade, the issue of organisational shortcomings has
emerged as a central focus, but there have been few, if any, proven
techniques or management systems for coping with such issues. We
are still discovering how to ensure organisations learn and change
when faced with accidents. At a wider level we need to address how
society learns, how to regulate industry, how to co-ordinate the
activities of the many various people responsible for safety within
given contexts (eg within transport networks). We must take
necessary action, but avoid knee-jerk, expensive and ineffective
reactions fuelled by the heat of emotions.
General
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