The Design Of Learning From Incident System Based On High Reliability Organization(HRO) Theory

Theory and practice show that there have been some precursor incidents and warning signs before the accidents.The organization involved failed to collect and analyze the information so that appropriate action could be taken to reduce the risk of disaster.Not effectively learning from the past incidents is one of the most important reasons for growing accident.On the basis of summarizing the current research of learning from incidents,it's necessary to build a system of learning form incidents.Incident in this paper can refer to any unwanted event that may have an adverse effect on safety,health,or environment,including disasters,accidents,near-miss,operational error,warning signs or precursor incidents.By reviewing the literature of learning from incidents,this paper finds the obstacles in incident reporting,investigation analysis,information communication and corrective action,and the specific problems are also discussed.To improve the effectiveness of learning from incident and prevent future similar accidents,high reliability organization(HRO)theory is adopted as a guideline to build the incident learning system.This system includes six steps: initial reporting,selection of incident,investigation analysis,information dissemination,correction and evaluation.The content and method of every step of the learning from incidents system is detailed designed.In order to verify the validity of the incident learning system,a system archetype of “limits to growth”-a basic tool of system thinking is used to analyze the barrier to learn from incidents,establish the sub-archetype of incident reporting,investigation analysis,dissemination of information and correction.Measures based on HRO are added to the sub-archetype to weaken the negative feedback and then to formulate the archetype of “limits to growth” of incident learning system.The result confirms that the incident learning system based on HRO can overcome the difficulties during learning from incidents to improve the ability to prevent accidents by continuous improvement.In the last,some suggestions are given to the company in the following learning from incident activities.