How Do You Know If You’re Learning from Incidents?

摘要

Objectives/Scope: Despite the importance of learning from incidents, little is known about the indicators that signal whether people have actually learnt. Previous research has shown that learning is dependent on context; a software engineer and an operator at a petrochemical plant display learning in different ways, so the indicators of whether or not they have learnt will differ. Therefore it is important that energy organisations are able to recognise indicators of learning following an incident that are relevant to their context. The objective of this study is to explore ways of understanding whether individuals are learning from incidents, and provide a general model that companies can use as a starting point in evaluating learning. Methods, procedure, process: The Open University, in collaboration with the Energy Institute, undertook interviews with 18 workers at a European site of a multinational energy company. The participants came from a variety of positions in both operations and maintenance, ranging from front-end operators to managers. A model of professional learning was used to guide a thematic analysis of what participants viewed as effective learning from incidents. Results, observations, conclusions: The interviews provided many examples of ways that individual practice and site processes had changed as a result of learning from incidents. Indicators of learning ranged from individual traits, such as accurate perception of risks, to changes in leadership priorities. While the number of incidents has been used in both research and practice as an indicator of learning, the interviews demonstrated that there are many ways in which learning can be evidenced. Understanding what changes are important for individuals, teams, leadership, and the company as a whole is a first step to being able to assess if effective learning is taking place. Our preliminary findings indicate that there is no single measure that can be used to assess how well people learn. However, once a company has defined what changes it expects to see, a combination of measures could be created to give insight into how effectively learning is happening. Novel/additive information: This paper aims to provide some examples of indicators of learning after an incident. Both in research and in practice a single metric is often used to assess whether learning is occurring. This study proposes a model that would allow companies to select appropriate metrics for various aspects of learning from incidents.