Learning from accidents – What more do we need to know?

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 field 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 sufficiently self-reflective. 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 efficiency 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.     

A multiple instrument approach to quantifying the movement patterns and habitat use of tiger (Galeocerdo cuvier) and Galapagos sharks (Carcharhinus galapagensis) at French Frigate Shoals, Hawaii

We equipped individual tiger (Galeocerdo cuvier Péron and Lesueur, 1822) and Galapagos (Carcharhinus galapagensis Snodgrass and Heller, 1905) sharks with both acoustic and satellite transmitters to quantify their long-term movements in the Papahanaumokuakea Marine National Monument (Northwestern Hawaiian Islands). Tiger sharks exhibited two broad patterns of behavior. Some individuals were detected at French Frigate Shoals (FFS) year round, whereas others visited FFS atoll in summer to forage on fledging albatross, then swam thousands of kilometers along the Hawaiian chain, or out into open ocean to the North Pacific transition zone chlorophyll front, before returning to FFS in subsequent years. These patterns suggest tiger sharks may use cognitive maps to navigate between distant foraging areas. Different patterns of spatial behavior may arise because cognitive maps are built up through individual exploration, and each tiger shark learns a unique combination of foraging sites. Galapagos shark detections were all associated with FFS, suggesting these sharks may be more resident around oceanic islands. Both Galapagos and tiger sharks primarily used the mixed layer (<100 m depth) and made occasional deeper dives through the thermocline down to 680 m. Results show reef-associated sharks utilize a wide variety of habitats ranging from shallow atoll lagoons to deep reefs and open ocean and may provide important trophic links between these habitats.