Learning from Incidents

disasters have occurred because organizations have ignored the warning signs of pre-cursor incidents or have failed to learn from the lessons of the past. Risk is inherent in many high technology systems, but society views the benefits of continuing to operate these systems as outweighing the cost of the occasional disaster. Must we continue to live with disasters? Normal accident theory sees accidents as the unwanted but inevitable output of complex systems, while high reliability theory sees accidents as preventable by certain characteristics of the organization. This paper proposes that an incident learning system can provide a bridge between these two theories. By learning from the incidents that inevitably occur in a complex system, an organization can reduce risk and minimize loss. Thus, an organization with an effective incident learning system sustains a process of continuous improvement that allows it to become a high reliability organization over time. Incident learning theory suggests that implementing a system to encourage reporting of more incidents will drive a cycle of continuous organizational improvement that will reduce incident severity and reduce risk of disaster.

The ideal learning from incidents layered cake.

Which incidents should you investigate? - - Respond Faster. See Patterns. Learn From Your Incidents.

EHS on Tap: E29 Root Cause Analysis: Learning from Incidents to Improve Prevention - EHS Daily Advisor

Use incidents as a learning opportunity · DigiLEAN

Learning from incidents

How machine learning strengthens incident management

Learning from Incidents

Incident Response Phases - Lessons Learned - Halkyn Security Blog

Learning from incidents and accidents: The gift of failure

Use incidents as a learning opportunity · DigiLEAN

Learning from Incidents

An Effective Lessons Learned Program - Pipeline Performance Group, LLC

PDF] Research and development agenda for Learning from Incidents Journal Item

The learning cycle for incidents.