Safety Science 48 (2010) 714721

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/ssci

Learning from accidents What more do we need to know?

Anna-Karin Lindberg a,*, Sven Ove Hansson a, Carl Rollenhagen a,b
a
b

Department of Philosophy and the History of Technology, Division of Philosophy, KTH, Teknikringen 78B, 100 44 Stockholm, Sweden
Vattenfall Power Consultant, Box 527, SE-162 16 Stockholm, Sweden

a r t i c l e

i n f o

Article history:
Received 25 April 2008
Received in revised form 10 March 2009
Accepted 5 February 2010

Keywords:
Experience feedback
Accidents
Incidents
Evaluation studies
Accident investigation
CHAIN model

a b s t r a c t
A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the eld of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are
presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that
the discipline of experience feedback has not been sufciently self-reective. The process of experience
feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies
and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efciency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation,
(3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive
measures, and (4) studies of the integration of experience feedback systems into overall systems of risk
management.
2010 Elsevier Ltd. All rights reserved.

1. Introduction
In order to prevent accidents it is essential to learn from previous accidents and incidents. Much learning from accidents occurs
spontaneously, such as when a child changes her behaviour after
fallen off her bicycle. In other cases learning from accidents has
to be institutionalized in order to overcome various social barriers
and to disseminate information so that new insights in accident
prevention are as widely applied as possible. Both governmental
and private organizations have been created to ensure that the
appropriate conclusions are drawn from accidents. One of these
organizations, the Swedish Centre for Lessons Learned from Incidents and Accidents (NCO) has described the systematic learning
from accidents as follows:
Learning from accidents is to extract, put together and analyse
and also to communicate and bring back knowledge on accidents
and near-accidents, from discovery to course of event, damage,
and cause to all who need this information. The purpose is to prevent the occurrence of similar events, to limit damage, and thereby
improve safety work.1
The scientic literature on experience feedback from accidents
has grown signicantly in the last few decades. However, this liter-

* Corresponding author. Tel.: +46 (0) 8 790 94 25; fax: +46 (0) 8 790 95 17.
E-mail address: a-klindberg@infra.kth.se (A.-K. Lindberg).
1
Swedish Rescue Services Agency: www.srv.se/nco Downloaded 2006-06-01.
(Translation from Swedish by the authors.)
0925-7535/$ - see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2010.02.004

ature is still rather fragmented, and much remains to be done to

develop a unied and integrated approach to learning from accidents that integrates knowledge and experience from different disciplines and elds of application. Furthermore, most of the
literature focuses on certain parts of the experience feedback process, in particular accident investigation methodology. Much less
has been written on the activities that take place before or after
the accident investigation, such as initial reporting, selection of
accidents for investigation, dissemination of information, and
experience-based accident prevention. It is the purpose of the present paper to present a perspective on experience feedback that
covers the whole process, and to identify major research needs related to the different components of that process.
In this paper we will present an overview of the eld of learning
from accidents and identify areas in need of further research. Our
focus has been on research that describes and evaluates procedures
intended to promote learning from accidents and incidents. Literature that reports the outcomes of particular accident investigations
has only been included to the extent that we found it relevant for
the more general theme of our study. We have paid particular
attention to literature that evaluates, from various points of view,
the usefulness of different methods and organizations for accident
investigation and related activities. However, in particular in areas
where the evaluative literature is small or non-existent, descriptive
literature is also referred to. The Science Citation Index was used as
our primary bibliographical source. The search was mostly carried
out in the years 20052007. It was restricted to publications in

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A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

English and primarily focused on literature not older than 1990.

Our focus has been on articles in peer-reviewed journals. We have
primarily used the keywords: accident, incident, prevention, lessons learned, and near misses.
In Section 2 we present a model of experience feedback as a
process in ve steps, and in Sections 37 we summarize our ndings on the available research literature on each of these ve steps.
In Section 8 we discuss research that refers to the feedback process
as a whole, and in Section 9 we recapitulate and summarize what
we consider to be some of the most important research tasks in
this eld.
2. The stages of accident investigation
In this section we will present the CHAIN model of experience
feedback that we have developed to ensure that all important
phases of the process are covered. This is the model that we have
used to systematize our literature search and our review of needs
for additional research.

occurred. Recommendations from the investigation must be stated

and implemented, and then disseminated. According to these
authors the exchange of information is important because other
groups within an organisation may react to protect themselves
against similar mishaps (Johnson and Holloway, 2003, p. 273).
One important feature of the CHAIN model is that it describes a
process that is truly a chain in the sense that the process as a whole
fails if any one of its links fails. If accidents are not adequately reported, or if the selected accidents are not those from which
important lessons can be learnt, or if the investigation fails to identify preventable causes of the accidents, or if the results do not
reach those who can prevent new accidents, or if information
about the results do not trigger preventive action, then the whole
process of accident investigation has failed its purpose.
We will use the stages of the CHAIN model to organize our literature ndings, but our discussion and analysis will not be restricted to that model.

2.2. Six quality criteria based on the CHAIN model

2.1. The CHAIN model
The CHAIN model was rst developed for an evaluation of the
Swedish Work Environment Authoritys accident investigation
board (Lindberg and Hansson, 2006) but it was constructed with
a view to being applicable also in other sectors. It species a chain
of accident investigation steps, as shown in Fig. 1. The rst step in
the CHAIN is the reporting of accidents (and possibly incidents)
from industries or other places where they have occurred. The second step is the selection, based on these reports, of accidents or
incidents for further investigation. The third step, investigation, is
the centrepiece of the process. The fourth step is the dissemination
of the results obtained to those responsible for preventing new
accidents. The fth step is the actual prevention of such accidents.
This model summarizes ideas that are well-known from the
accident investigation literature. Hence, Johnson and Holloway
(2003) have described the investigation of mishaps as follows.
First, the mishap must be detected and reported. Then relevant
information about it must be gathered and interviews made with
eyewitnesses. When the information needed is collected, the investigators can perform their analysis. When they have come to a conclusion about what happened, it is time for them to nd out why it

We have used the CHAIN model as a point of departure for

developing six overarching quality criteria for experience feedback.
The rst ve of these refer to the ve phases outlined in the model.
Beginning with the rst phase, the initial reporting of accidents
and incidents provides the starting-point for the whole process.
The reporting of accidents may also have other purposes, but to
the extent that it is performed for the purpose of experience feedback, it has to cover all events that are candidates for accident
investigation and contain sufcient information about each of
them for a decision whether it should be further investigated. In
the next stage in the process, the selection of events for further
study, the goal is to select events from which as much useful information for preventive work as possible can be extracted. The
timely satisfaction of this goal should be the central quality criterion for this phase of the process. In the investigation stage, the
goal is to uncover such information about the causal factors behind
the investigated event that can be used to prevent future accidents.
(See Section 5.1 for a discussion of the more detailed requirements
on process and methodology of this stage.) The essential requirement on the dissemination phase of the process is that this information should reach all those who can use it to prevent

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Accident
investigation
g
board

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

Workplace

W k l
Workplace

W k l
Workplace

Reporting

Selection

Investigation

Dissemination

Fig. 1. The CHAIN model of accident investigation and prevention.

5
Prevention

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A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

accidents. The goal of the nal stage in the process is that, based on
this information, such accidents should be prevented.
Finally, the method of experience feedback should be applied to
the process itself. In other words, the process should be self-reective, and include evaluation activities that lead to improvements of
the process. In summary, our six basic quality criteria for experience feedback are as follows:
 Initial reporting. All events that are plausible candidates for indepth accident investigation should be reported in sufcient
detail for a decision on whether such an investigation should
take place.
 Selection methodology. The events selected for in-depth investigation should be those from which as much information as possible can be extracted that is useful for preventive work.
 Investigation. The procedures and methodologies of investigation
are constructed to provide information that is as useful as possible for the prevention of future accidents.
 Dissemination of results. The investigation results are distributed
to all those who can use them to prevent future accidents.
 Preventive measures. The information from accident investigations is used to prevent future accidents.
 Evaluation. The experience feedback process is regularly evaluated, and is itself improved through experience feedback.

oped systems for the reporting of accidents and incidents; these

are also industries with extensive international exchange and
cooperation in accident reporting.
In contrast, the reporting of accidents occurring on leisure time
is unsystematic or non-existent, in spite of the high prevalence of
such accidents. Lethal accidents in homes are much more common
than what is usually believed (mostly elderly people falling in their
homes), but they are not subject to systematic reporting. Similarly,
routines are lacking for reporting accidents in the tourism industry.
Without accident reports, systematic experience feedback to improve safety is not feasible (Bentley et al., 2001).
Hence, there are large differences between different sectors and
industries in the prevalence of accident reporting. Most notably,
accident reporting is yet lacking in some sectors with many
accidents.
Much less is known about the satisfaction of the other two criteria for initial reporting, namely those that concern the quality of
the reports and the promptness with which they are delivered. We
have not been able to nd any literature that evaluates initial
reporting from these points of view. Such studies would be of
interest, not least since there is an interesting conict between
quality and promptness. More time is required to produce a fuller
report, and somehow a balance must be struck.
3.2. Incident reporting

3. Initial reporting
The rst stage in the learning process is the initial reporting of
accidents and incidents. What events are reported depends on how
accidents are dened, and on the routines and regulations for
reporting (Duffey and Saull, 2003).
In Section 3.1 we focus on the basic requirements for initial reports. In the following two subsections we discuss two topics that
have been dealt with fairly extensively in the research literature,
namely whether reporting should include incidents that did not
develop into completed accidents (Section 3.2) and the use of databases for the collection of reported accidents and incidents (Section 3.3).
3.1. Basic requirements on initial reports
The quality requirement on initial reporting that was mentioned in Section 2.2 can be operationalized by dividing it into
three components: (1) All plausible candidates for in-depth accident investigation should be reported. (2) These initial reports
should contain the information needed for the selection of events
for in-depth investigation. (3) These reports should reach those
who make this selection, and reach them as soon as possible after
the event.
Concerning the rst of these criteria, the coverage of reporting,
a fair amount of empirical information is available in the research
literature. It is well-known how the reporting of accidents is organized and how it differs between sectors and between individual
companies and organizations (Kjelln, 2000; Cox et al., 2006).
Many countries have legislation that requires employers to report
occupational accidents to the authorities (Kjelln, 2000). The quality of reporting differs between countries and between types of
industry. Generally speaking, accidents in smaller companies and
accidents not leading to severe injuries tend to be underreported.
Several sectors have industry-specic reporting systems that cover
both occupational risks and risks to the public. Hence, most industrial countries have reporting systems that cover accidents on
roads and in the railroad system. The aviation industry, the nuclear
industry and the offshore oil and gas industry all have well-devel-

Companies and authorities can learn from their incidents and

near misses without having to suffer the consequences of a full
accident. Investigations of incidents therefore provide information
that can be instrumental in avoiding recurrence of subsequent failures (Kjelln, 2000; Johnson and Holloway, 2003). Several authors
claim that there is a relationship between the numbers of near
misses, minor incidents, and major accidents (Bird and Germain,
1966; Tye, 1976; Heinrich, 1980. cf. Jones et al., 1999). Another factor that contributes to the value of investigating incidents and near
misses is the openness in such investigation work, as compared to
investigations of serious accidents (Rollenhagen, 2003). Investigations of incidents where new technology or a new form of organizations is involved are particularly useful.
Dien et al. (2004) use the Paddington accident in 1999 to exemplify the importance of incidents. In this accident, two trains running in opposite directions on the same track collided. Thirty-one
persons were killed and 400 injured. The direct causes were difculties to see the signals in low sunshine and inadequate training
of the engine drivers. After the accident it was revealed that eight
similar incidents had already occurred. Dien and co-workers conclude that dysfunctions and their deep causes and aggravating
factors, both of a technical and organisational nature, pre-exist
without any accident occurring (Dien et al., 2004, p. 151).
Management sometimes has a reluctant attitude to near miss
reporting (Barach and Small, 2000). However, the resistance seems
to be receding, and many industrial companies have recognised
that they can learn from their own near misses without having
to suffer the consequences from a full accident. Hence, Norsk Hydro started a programme offshore in the late 1980s to increase
the internal near miss reporting. It turned out that the number of
accidents decreased when the line leaders managed to achieve
an increased focus on reporting of near misses and learning from
them. Today near miss reports are used as an important tool of
safety and are included in the training of all employees. Norsk Hydro believes that this creates safety awareness in the whole organisation and that lessons can be learnt from minor misses. They
encourage their employees to report mistakes without any risk of
being punished (Jones et al., 1999).
A reporting system can be open, condential or anonymous.
Fernald et al. (2004) believe that condential reports are more

A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

likely to include sufcient information to allow detailed coding

than anonymous (or open) reporting. (For more details, see Johnson, 2002.) Reports about incidents are much less likely to be made
if they can lead to disciplinary action. Rall et al. (2001) and many
others have claimed that the so-called culture of blame that focuses on individuals has to be replaced by a safety culture that instead sees errors and incidents as problems for the whole
organisation. Employees are also often unwilling to report the
behaviour of colleagues or more senior staff. Therefore, as pointed
out by Johnson and Holloway (2003), efcient incident reporting
requires that reports can be made without fear of disciplinary action. According to Ashcroft and Cooke (2006) there are indications
of underreporting of adverse incidents in the healthcare sector,
especially in non-condential reporting systems. One anonymous
reporting system that seems to be working properly is the Aviation
Safety Report System (ASRS). This is a voluntary system that is
administered by the National Aeronautics and Space Administration (NASA). It has received over 500,000 submissions (Johnson,
2002; Anderson et al., 2006).
In our view, the available research literature provides sufcient
evidence that incident reporting can increase the efciency of an
experience feedback system. However, more research is needed
in order to determine how reports on incidents are best elicited
in different types of organizations.
3.3. Accident databases
Reports about accidents are often collected in databases. Several
such databases have been well described in the literature (Drogaris, 1993; Kirchsteiger, 1999b; Balasubramanian and Louvar,
2002; Scott et al., 2002; Uth and Wiese, 2004). A much studied
database is the Major Accident Reporting System (MARS) that
was set up in 1984 by the European Commission to handle information on major accidents submitted by its member states in
accordance with the Seveso Directive2 (Drogaris, 1993; Jones
et al., 1999; Kirchsteiger, 1999a,b; Balasubramanian and Louvar,
2002; Nivolianitou et al., 2006). The total number of reports in MARS
was 498 in 2003 (Nivolianitou et al., 2006). This is a rather low number of reported events but instead the level of detail is high in the
reports (Kirchsteiger, 1999b). Both EU and OECD member countries
use MARS to report industrial accidents.3 Balasubramanian and Louvar (2002) have pointed out that it is easy to search in MARS, and
that the information it provides is very useful. A positive experience,
according to Drogaris (1993), is that collection of accident data, elaboration of reports and dissemination of lessons learnt is possible
without endangering industrial secrecy.
The German Zentrale Melde- und Auswertestelle fr Strflle
und Strungen in verfahrenstechnischen Anlagen4 (ZEMA) has been
in operation since 1993. It is a permanent federal body for accident
investigation within the Federal Environment Agency that collects,
documents, analyses and disseminates information about major
accidents from hazardous installations. A ZEMA investigation is carried out in close cooperation with competent local authorities. ZEMA
is also fully compatible with MARS (Uth and Wiese, 2004).
The Swedish Trafc Accident Data Acquisition (STRADA) is
administered by the Swedish Road Administration. The police send
reports about all trafc accidents that they investigate to STRADA.5

2
Joint Research Centre: http://mahbsrv.jrc.it/Activities-WhatIsMars.html Downloaded 2006-01-09.
3
Joint Research Centre: http://mahbsrv.jrc.it/mars/Default.html Downloaded
2007-06-14.
4
English translation: Central Reporting and Evaluation Ofce for Hazardous
Incidents and Incidents in Process Engineering Facilities.
5
Swedish Road Administration: http://www20.vv.se/fudinfoexternwebb/pages/
ProjektVisaNy.aspx?ProjektId = 1260 Downloaded 2006-06-16.

717

Information and analyses about passenger behaviour in aviation

accidents is stored in the Aircraft Accident Statistics and Knowledge (AASK) database. The information in AASK comes from the
U.S. National Transportation Safety Board (NTSB), the U.K. Air Accident Investigation Branch (AAIB), and the Australian Transport
Safety Bureau (ATSB). It consists of interviews with survivors from
aviation accidents. According to Galea et al. (2006) the AASK database is unique, containing data from over 2000 passengers and
crew statements from 105 accidents (Galea et al., 2006).
The research literature contains descriptions of several other
accident databases such as:
 Analyse et recherche dinformation (ARIA) (Pineau, 1999).
 The Major Hazard Incidents Data Service (MHIDAS) (Carol et al.,
2002).
 FACTS (Sonnemans et al., 2003).
 The Accident Release Information Program (ARIP) (Balasubramanian and Louvar, 2002.
However, more in-depth analyses of the actual use of such
databases are lacking. According to Trevor Kletz (2002), accident
databases have been used less than expected. It seems as if persons responsible for accident prevention do not use accident
databases as a tool for general learning but only refer to them
when they are already aware of a hazard. Since considerable
resources are being spent on the creation, updating, and maintenance of accident databases, this is not satisfactory. Possibly,
databases may have to be reconstructed in order to be as useful
to their intended users as they are intended to be. Therefore,
research on the actual use and usefulness of accident databases would be a valuable contribution to the accident prevention literature.

4. Selection
The second step in the CHAIN model is the selection of accidents and incidents for investigations. The selection process depends on the size and structure of the organisation, the
investigation resources and the number of accidents of different
types. An organisation with many non-serious accidents may
have to exclude many accidents from in-depth investigation,
whereas an organisation where accidents are rare but serious
has good reasons to investigate all of them, and probably also a
signicant number of incidents and near-accidents. Sectors with
a tradition of careful investigations of accidents and serious incidents include aviation, the nuclear industry, space programmes,
and the offshore oil industry. In most sectors with many accidents, the only feasible strategy is to investigate only a selection
of the accidents.
The selection of accidents for investigation can be performed in
different ways, for instance with a preference for representative
accidents, unusual accidents, accidents with unknown causes, or
accidents with particularly serious outcomes. For instance, workplace accidents in the Netherlands are selected by the following
criteria: accidents causing death, permanent injury, or inpatient
treatment in hospital (Hale et al., 2007a,b). The selection criteria
for in-depth investigations performed by the Swedish Work Environment Authoritys accident investigation board were fatal
accidents, accidents in the building and process industries, accidents involving heavy machinery, accidents involving several
employers, accidents that can generate signicant media interest,
and accidents of national interest (Lindberg and Hansson, 2006).
The Swedish accident investigation board (SHK) that investigates
accidents in several areas such as aviation, shipping, road and rail
trafc, chemical accidents etc. use rather simple criteria. It is the

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A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

seriousness of the accident that determines whether it will be

investigated by the SHK.6
As noted in Section 3.2, incident reporting has an increasingly
important role in the development and maintenance of safetycritical applications. However, as has been pointed out by Johnson
(2002, p. 767), some incident investigation systems may have become victims of their own success. A growing number of reports
also require an increasing number of follow-up investigations, and
this may lead to delays in the investigation. If investigations take
place too long after the event, witnesses may forget signicant details about the incident (Johnson, 2002). This makes the selection
process particularly important in a reporting system that receives
a large number of incident reports.
It is of course essential that the selection process does not exclude certain types of accidents, or accidents with certain types
of causes, from which important lessons can be learnt. If it does,
then the efciency of the learning process can be seriously impaired. However, in spite of the importance of the selection process, very little seems to be said about it in the research
literature. To nd out how an adequate selection process should
be constructed, studies are needed in which actual selection processes are checked against carefully constructed adequacy criteria.
In our view, such criteria could be based on the quality criterion for
the selection process that we proposed in Section 2.2, namely that
events should be chosen from which as much useful information as
possible for preventive work can be obtained in a subsequent
investigation process.

 use a broad scope of information sources, such as interviews,

documents, and technical analyses, and
 whenever appropriate make use of, and draw parallels to, previous investigations of other accidents.
Concerning the model used for understanding the accident, previous authors have emphasized the need for a methodology that
 includes both direct causes and indirect, underlying causes of
the accident, such as organizational failures and lack of safety
culture (Choularton, 2001; Rollenhagen, 2003),
 includes causal factors further back in time (the accident incubation period) (Turner, 1997. cf. Dien et al., 2004),
 has been validated (Katsakiori et al., 2009).
Finally, concerning the outcome of the investigation, it has been
emphasized in the literature that an accident investigation should
 result in a written report (Kletz, 1993), and
 recommend how similar accidents can be prevented in the
future (Rozental, 2002).
We propose that these 10 criteria can be used as an experiencebased list of qualities that should be striven for in accident
investigations.

5.2. Accident investigation methods

5. Investigation
The third step in the CHAIN model is the actual investigation of
accidents. Much has been written about this process. Most of this
literature consists of proposals for how an accident investigation
should be performed. Still, as concluded by Groeneweg (1998)
accident investigation struggles with a lack of a practical application of a theory about how and why accidents happen.

5.1. Quality criteria for the investigation process

In Section 2.2 we proposed that the overarching quality criterion of the investigation process should be that it should provide
information that is useful for the prevention of future accidents.
In order to make this criterion more operative, it has to be supplemented with more detailed criteria. Such criteria, or goals for the
investigation process, have indeed been proposed by many
authors. These detailed criteria can be divided into three major categories, according to whether they refer to the procedure of investigation, the model used for understanding the accident, or the
output of the investigation.
Concerning the procedure of investigation, previous authors have
emphasized that the investigation should
 be performed by independent investigators (Baxter, 1995),
 be conducted as soon as possible after the accident (Rozental,
2002), and
 provide a detailed description of the accident (Katsakiori et al.,
2009).
To this we would like to add two further criteria, namely that
the investigation should
6

23.

Swedish Accident Investigation Board: www.havkom.se Downloaded 2006-11-

A large number of accident investigation methods have been

described in the literature. An overview can be found in Sklet
(2004). Several methods are also described in detail in a workbook
compiled by the US Department of Energy (DOE), Conducting Accident Investigations (1999). The purpose of this workbook is to provide practical advice for accident investigations. Four core analytic
techniques are described that are generally used within DOE accident investigations. (Event and causal factors charting, Barrier
analysis, Change analysis, and Root cause analysis.) Katsakiori
et al. (2009) have recently written a brief review of accident investigation methods.
Accident investigation methods are closely associated with
accident models that reect different views of causality, human
agency, and moral responsibility (Kjelln, 2000; Rollenhagen,
2003; Hollnagel, 2004). Accident models may be conceptualized
both as intuitive and culturally determined folk models and in
a more formal academic fashion. In both cases they may inuence
both what are assumed to be important causal factors behind accidents and what types of remedial actions are proposed. Examples
of inuential accident models are Heinrichs (1959) model that focuses on removing unsafe acts and conditions at workplace, Gibsons (1961) energy model (rooted in epidemiology) with its
focus on energy sources (electrical, chemical, etc.), Haddons phase
model (1968), originally developed for analysis of trafc accidents
and then generalized to other types of accidents, the TRIPOD model
(Reason, 1991) that includes cultural and managerial elements,
and the Multi-linear Events Chartering Method (Benner, 1975) that
focuses on interacting conditions and events. Hollnagel (2004) divided accident models into three (partly overlapping) categories:
(1) sequential models with specic causes and well dened links;
(2) epidemiological models that focus on concepts such as barriers
and latent conditions; and (3) systemic models with great inuences from control theory, systems theory, etc. The rst two types
of models postulate clear cause-effect links whereas the third
treats accidents as emergent phenomena arising from the complexity of systems whose behaviour cannot be fully predicted from
an analysis of its constituent parts.

A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

In 2001/2002 the European Safety, Reliability and Data Association (ESReDA) commissioned a study of accident investigation in
three sectors. The sectors were transport, energy production, and
production and storage of hazardous materials. A questionnaire
was sent out to about 150 organisations and 49 answers were treated in the ESReDA report covering 15 countries in Europe. A 53% of
the answers came from an organisation or institution in a Nordic
country. The respondents were divided into three main categories:
authority (27), company (15), and research (7). The study showed
that the main stated objectives of the investigation teams were to
collect facts, to nd primary and underlying causes of an accident,
and to prevent similar accidents in the future. Accident investigation boards/bureaus usually have investigators on their own payrolls, but sometimes they also contract external investigators.
Other authorities or government bodies, research centres, and universities have either permanent investigators or temporary investigation teams. Only 11 of the organisations stated that they used
some kind of recommended investigation method. The largest
group answered that they had no standard method for the investigation of accidents (Roed-Larsen et al., 2004).
Le Coze (2008) compared the investigation methods used in different types of accident investigations. He concluded that different
type of investigation tools should be used, depending on the purpose and the resources of the particular investigation.
As already mentioned, descriptions of various methods for the
investigation of accidents take up a large part of the literature on
experience feedback. However, we have not been able to nd studies that systematically evaluate and compare these methods with
respect to their efciency in identifying measures to be taken to
avoid future accidents. Such studies should, in our view, be an
important addition to the literature. They would have to pay close
attention to the underlying conceptualizations of causality, agency,
and responsibility that shape these methodologies.

6. Dissemination
The fourth step in the CHAIN model is the dissemination of reports and information on the accident. Several authors have
emphasized the importance of efcient dissemination of accident
investigation reports. According to Johnson (2002), a major reason
for failure of dissemination may be that investigation reports are
too long and not written in a sufciently accessible language. Johnson and Holloway (2003) point out the importance of ensuring that
insights gained from an accident investigation are disseminated
both within and between organisations. Amoore and Ingram
(2002) emphasize the importance of dissemination of information
in healthcare, particular about failures of medical devices. In an
evaluation of the Swedish accident investigation board for workplace accidents (Lindberg and Hansson, 2006) it was found that
the dissemination stage was the weak link in the chain, leaving
considerable scope for improvement.
According to Trevor Kletz it is a major problem that even when
lessons are learnt, they are often soon forgotten. He proposes that
both new and old accidents should be discussed in safety newsletters and on safety meetings, making use of knowledge from people
with long experience. Serious accidents should be discussed in the
training of new personnel. He also proposes that old reports be
made more accessible (Kletz, 1993). Even when we prepare a
good report and circulate it widely, all too often it is read, led
and forgotten. Organizations have no memory. Only people have
memories and after a few years they move on taking their memories with them (Kletz, 2002, p. 5).
One organisation that has put considerable effort into the dissemination of information from accident investigation is the US
NTSB. Since its inception in 1967 it has issued about 12,000 safety

719

recommendations to more than 2200 recipients in all the modes of

transportation. The NTSB makes recommendations to everyone
who can make a change that improves safety.7 According to Sweedler (1995) the NTSB has had a signicant positive impact on the
safety of the US transportation system, and the changes being made
from its recommendations have saved thousands of lives. The Board
has set up an Ofce of Safety Recommendations whose main function is to work towards the highest possible rate of acceptance of
NTSB recommendations. The majority of the NTSB recommendations
(58%) are directed towards the US Department of Transportation.
The department is the only recipient of recommendations that has
to respond formally to NTSB within 90 days. The answer should contain what action it plans to take concerning each recommendation,
and if no action is planned, explain why. Other recipients of the recommendations, such as State Governors, private airlines, and railroads have also chosen to give the NTSB responses even though
they are not legally required to do so. All the incoming answers
are taken care of and the action planned is thoroughly reviewed.8
In summary, we have found only few studies of the dissemination of information from accident investigations. It seems to be a
generally accepted problem that the dissemination of reports from
accident investigation is often insufcient. Since this is an essential
link in the chain of accident investigation activities it is an obvious
priority for further studies. Such studies should in our view be
based on the quality criterion for dissemination that was proposed
in Section 2.2, namely that the essential information obtained in
the investigation be distributed to all those who can use them to
prevent future accidents.

7. Prevention
As was noted by Johnson and Holloway (2003), an accident
investigation process has not come to an end until its recommendations have been implemented for the future safety of the system
to be protected. Similarly, Sweedler (1995) emphasizes that accident investigation is just one step along the way. The investigation
does not in itself improve safety or prevent accidents. The real
change takes place when these recommendations are
implemented.
We have only found a few studies of the effects of accident
investigations on actual preventive measures. As was mentioned
in Section 6, the implementation of proposals by the NTSB has been
evaluated. It was found that as many as 82% of the recommendations have been adopted by those for whose action they are intended (Sweedler, 1995). The evaluation of the Swedish accident
investigation board for workplace accidents (Lindberg and Hansson, 2006) followed through the proposals of the investigation
board and asked those to whom the proposals had been addressed
whether the proposals had been implemented. The result was
mixed. In several cases, the proposals had been used and had
reportedly given rise to preventive measures. However, in some
cases, the respondents reported that they had not been given the
opportunity to act on the investigation report, either because it
had not reached them at all or because it was nished only after
they had already decided on what measures to take.
The purpose of MARS is to help companies prevent the repetition of accidents from the past. However, Balasubramanian and
Louvar (2002) report that as yet, the efforts made to ensure that
the recommendations of MARS lead to actual prevention have been
insufcient.
There are too few follow-up studies of the actual effects of acci7
National
Downloaded
8
National
Downloaded

Transport Safety Board: http://www.ntsb.gov/Abt_NTSB/history.htm

2007-06-14.
Transport Safety Board: http://www.ntsb.gov/Abt_NTSB/history.htm
2007-06-14.

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A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

dent investigation reports on actual preventive measures. In our

view, such studies should be given high priority in future research.
Error in design is one of the most frequent reasons for accidents
and system failure in process industries (Taylor, 2007a). According
to Taylor (2007b) design errors can be avoided with better design
techniques and better design review. He states that it is possible to
reduce the number of design errors in operating plants and devices
10-fold. Still, he continues, there is much room for improvement
(Taylor, 2007b). Remedial actions as a consequence of ndings
from event investigations can, of course, be of many different
kinds. In a review article scrutinizing the success of different
change programs aimed at safety improvements, Lund and Aar
(2004) found that programs focused on attitude changes had at
most weak effects whereas programs focused on structural factors
(including technology changes) had better effects. Creating inherently safe technological design is an important strategy for enhanced safety. It should be supported by efcient experience
feedback systems. For example Hale et al. (2007a,b) wrote: The
single most important issue in improving the design process from
a safety point of view is how to ensure operational input (p. 321).
. . . designers have to learn from past accidents and errors. Incident and accident databases can assist in this, but they need to
be much more oriented to designers and much more accessible
to them. They also need a translation process to generalise from errors with old technology to the implications for designing its
replacement (p. 321). In general, it seems that experience feedback systems should be more adapted to the various potential user
groups (public, operational organisations, designers, etc.).

8. The process as a whole

Very few studies have been performed of the accident investigation process as a whole. A couple of studies have compared accident reporting and investigation in different countries. It is clear
from these studies that there are large differences between countries. For instance, de Almeida et al. (2000) point out the poorly
developed organisation of accident investigation in Brazil. The
ESReDA study compared accident investigations in Europe (RoedLarsen et al., 2004).
An important general topic in the study of experience feedback
is how its role may vary in the prevention of different types of accidents. Rasmussen and Svedung (2000) discuss this on the basis of a
categorization of accidents into three major types: (1) occupational
safety, with a focus on frequent but small-scale accidents, (2) protection against medium size, infrequent accidents, and (3) protection against rare, large-scale accidents. The rst category
(occupational safety) includes a set of varied hazard sources in
loosely coupled work systems. The second category (such as aircraft safety) has usually identied a set of well-dened hazards
that have often, as seen in a historical perspective, been dened
by analysis of past accidents. The third category consists of tightly
coupled systems with a strong focus on defenses (barriers) dened
as an outcome of risk analysis.
Rasmussen and Svedung (2000) argue that the rst of their
three types of accidents is mainly controlled on the basis of epidemiological studies from a large set of minor past accidents whereas
the second category requires more focus on design improvements
in response to analyses of the individual, latest major accident
(Rasmussen and Svedung, 2000, p. 27). Finally, accident management in the third category cannot be based only on experiences
from past events but must involve a much stronger element of risk
analysis in the safety management system. Rasmussen and Svedung also argue that the safety management practices previously
associated with different accident types should be reconsidered

in the future more proactive safety management practices should

be introduced for all kinds of accident types.
Although the typology outlined by Rasmussen and Svedung has
the merit of discerning some aspects of different safety management strategies viewed from a historical perspective, modern
safety management has a much more diversied approach to various accident types. Risk analysis always depends on empirical
data, and consequently on experience feedback systems. However,
it is common to nd that experience feedback systems are not systematically integrated with risk analytical efforts. The integration
of experience feedback systems into overall systems of risk management is an important area for future research.
Another interesting and rather unexplored aspect of recommendations from accident investigation reports concern how various types of recommendations t with expected (safety) maturity
levels of organisations (Fleming, 1999). It seem reasonable to expect that organisations with less developed safety management
systems and practices should not be approached in the same way
as those with more mature processes. To what extent accident
investigators take such a consideration into account when providing recommendations still seems as an open question.

9. Conclusions
The overall conclusion from this investigation is that the discipline of experience feedback has not been sufciently self-reective. Experience feedback is based on the idea that we can
improve by systematically and critically evaluating our previous
performance. This idea is fully applicable to experience feedback itself, but such applications are rare. Although there is a considerable literature on experience feedback processes, there is a lack
of evaluation studies that could provide hard (evidence-based)
information about the effects of various methodologies and organizational structures for accident investigation on the future prevalence of accidents. Intervention studies in which objects of
investigation (accidents or incidents) are randomized between different procedures or methods of investigation would provide the
best chances to determine the relative value of alternative methodologies (Hansson, 2007). Other studies increase our knowledge
about the workings and the efciency of experience feedback are
also needed. In this overview we have identied nine important
topics for future studies of experience feedback:
 Differences between reporting systems in different social sectors
and different countries.
 The quality of initial reports and the promptness with which
they are delivered
 How reports on incidents can be elicited in different types of
organizations.
 How accident databases are actually used.
 How accidents or incidents are selected for investigation.
 The efciency of different accident investigation methods, and
how the choice of methodology should depend on factors such
as the type of accident and the type of organisation in which it
occurred.
 How and to what extent conclusions from accident investigations are disseminated.
 The actual effects of accident investigation reports on preventive
measures.
 The integration of experience feedback systems into overall systems of risk management.
We give the highest priority to the last four of these issues, since
they are key issues for the development of evidence-based accident
investigation practices.

A.-K. Lindberg et al. / Safety Science 48 (2010) 714721

Acknowledgement
This research was supported by the Swedish Rescue Services
Agency (Grant PNR 04-30).
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