A framework for learning from incidents in the workplace

Learning from Incidents (LFI) in the workplace has been gaining increasing importance in the Health, Safety and Environment context. Although organisations adopt a variety of LFI initiatives, it is often unclear what learning approaches are the most appropriate and the most effective for different types of incidents across a range of contexts. The aim of the paper is to surface factors that are important for effective Learning from Incidents (LFI). The paper builds on a conceptual framework for learning from incidents, developed through an earlier study. This conceptual framework was validated through empirical data collected at two multinational corporations in the energy sector. From this data a refined framework for learning from incidents was devised with five factors important for LFI: participants of learning, type of incidents, learning process, type of knowledge and learning context. This framework can be used as an evaluation tool and as a guidance tool to develop holistic, organisational learning approaches.     

Integrated modelling of foraging behaviour, energy budget and memory properties

A predator's foraging performance is related to its ability to acquire sufficient information on environmental profitability. This process can be affected by the patchy distribution and clustering of food resources and by the food intake process dynamics.We simulated body mass growth and behaviour in a forager acting in a patchy environment with patchy distribution of both prey abundance and body mass by an individual-based model. In our model, food intake was a discrete and stochastic process and leaving decision was based on the estimate of net energy gain and searching time during their foraging activities. The study aimed to investigate the effects of learning processes and food resource exploitation on body mass and survival of foragers under different scenarios of intra-patch resource distribution.The simulation output showed that different sources of resource variability between patches affected foraging efficiency differently. When prey abundance varied across patches, the predator stayed longer in poorest patches to obtain the information needed and its performance was affected by the cost of sampling and the resulting assessment of the environment proved unreliable. On the other hand, when prey body mass, but not abundance, varied among the patches the predator was quickly able to assess local profitability. Both body mass and survival of the predator were greatly affected by learning processes and patterns of food resource distribution.     

Accident prevention approach throughout process design life cycle

The accident rate in the chemical process industry (CPI) has not been decreasing although majority of accident causes have been identified and could have been prevented by using existing knowledge. These recurring accidents show that the existing knowledge has not been used effectively. In this paper, accident knowledge learned from earlier accident analyses are utilized to predict the common design errors during chemical plant design. An accident prevention approach throughout process design life cycle is proposed for a safer design consideration where designers are guided to identify common design errors, accident contributors and critical points to look for. The accident prevention approach has been applied to analyze the BP Texas City Refinery Explosion and Fire tragedy.     

Operator-centred local error management in air traffic control

Introduction: A large number of air traffic control occurrences take place without resulting in loss of separation between aircraft. Unfortunately such occurrences are seldom reported and therefore not used for disclosing system weaknesses, such as inappropriate methods and procedures.The ATCC (Air Traffic Control Centre) Malmoe made a trial with local reporting of “learning occurrences”. The trial was ATCO-(Air Traffic Controller) centred. The study objectives were to evaluate if ATCOs would start to report after a defined training and marketing effort, if they could identify system weaknesses, if concrete actions for safety improvement would be taken as a result of the trial and to what extent expert support was necessary.Method and material: The trial period was eight months. The ATCO report would be made on a simple form, available on site. These reports would then be analysed in groups and the marketing and feedback efforts would be co-ordinated by the local flight safety group.Results: 43 reports were filed and analysed during the trial period. The initial motivational training and marketing was considered adequate. During the group discussions, the ATCOs identified system weaknesses within 40 of the reports. The resulting safety improvement actions included: the ATCC unit becoming more active in contacting the pilots and airline companies, the renaming of some waypoints (due to name similarities), the implementation of safer procedures when relieving ATCOs, the training of ATCOs in cockpit flight management systems, and the initiation of a research project primarily concerned with ATCO mental overload.Expert support was required in the beginning to help ATCOs focus on the system rather than on the individual.     

From the Whitehorse Mining Initiative Towards Sustainable Mining: lessons learned

Much debate has taken place within the mineral policy community about whether or not meaningful progress has been made towards more sustainable practices. This paper investigates the changing approaches towards sustainable development undertaken by the Mining Association of Canada (MAC) over a period of approximately 20 years. The analysis begins in the early 1990s when MAC initiated the Whitehorse Mining Initiative (WMI) and concludes in 2010 when the association was operating under a strategy entitled Towards Sustainable Mining (TSM). The goal is to consider the nature of the learning that has taken place towards sustainability within the mineral industry using the case of a leading national mining association. The investigation was undertaken through a literature review as well as key informant interviews with stakeholders affected by the Canadian Mining Industry. Findings suggest that MAC’s approach to sustainable development has shifted from an ambitious and holistic partnership involving a range of stakeholders to a focused, member-specific agenda that addresses a few performance issues. The transition to TSM was based on lessons learned through working with the WMI and subsequent efforts. It reflects broader corporate tendencies to address social and ecological issues through corporate social responsibility initiatives. The implications of these trends suggest that voluntary initiatives in and of themselves should not be expected to replace the comprehensive regulatory responsibilities historically provided by government.     

Developmental stress impairs song complexity but not learning accuracy in non-domesticated zebra finches (<Emphasis Type="Italic">Taeniopygia guttata</Emphasis>)

Food restrictions early in life can have adverse effects on the development of adult avian song structure. Nutritional deficiencies during brain development are thought to impair the growth of neural circuits responsible for learning and production of song in adulthood. Thus, the quality of song may reflect the quality of the singer due to the costs associated with neural development early in life. Recent investigations have focused on domesticated laboratory strains of zebra finches where early dietary deficiencies have significantly reduced the complexity of song and its sexual attractiveness. Domesticated zebra finches may be more sensitive to the early effects of moderate under-nutrition on song complexity than their non-domesticated counterparts. In an aviary experiment with non-domesticated zebra finch stock, we found that song complexity when measured by a linear combination of six variables was reduced in food-restricted birds, with syllable rate and maximum syllable frequency as the principal variables affected. The restriction had no effect on learning accuracy when song phrases of experimental birds were compared to those of their fathers.This result demonstrates that early nutrition may differentially affect the development of neural processes that influence learning accuracy and song complexity. While the finding of negative effects of dietary restriction on song complexity is robust for zebra finches and is not an artefact of domestication, it does not explain why some nutritionally stressed populations of wild zebra finches have more complex songs than those from other regions of Australia characterised by greater food availability.     

Remembering the Past,Anticipating the Future: Community Learning and Adaptation Discourse in Media Commemorations of Catastrophic Wildfires in Colorado

Wildfire may be the clearest example to date of a socio-natural hazard that is being exacerbated by climate change, making wildfire an essential lens through which to investigate learning and adaptation in the Anthropocene. Here, we study discourse about simultaneous and recurring catastrophic wildfires in Colorado newspapers. We find that the wildfires’ anniversaries served as opportunities for critical reflection on hazard causality and mitigation in local media, particularly the first anniversary and especially for a community that experienced two catastrophic wildfires in a row. Two mediated prospective memory practices—invoking hindsight as foresight and recognizing a new normal—contributed to this discourse. However, learning and adaptation discourse faded in local media at later anniversaries. These findings contribute to learning and adaptation scholarship by connecting the concept of mediated prospective memory to disaster-related media studies and attending to the intricacies of anniversary commemoration under circumstances of simultaneous and recurring disasters.     

Promoting system-level learning from project-level lessons: An analysis of donor-driven ‘indirect’ learning about EIA systems in Ghana and the Maldives

A growing number of low and middle income nations (LMCs) have adopted some sort of system for environmental impact assessment (EIA). However, generally many of these EIA systems are characterised by a low performance in terms of timely information dissemination, monitoring and enforcement after licencing. Donor actors (such as the World Bank) have attempted to contribute to a higher performance of EIA systems in LMCs by intervening at two levels: the project level (e.g. by providing scoping advice or EIS quality review) and the system level (e.g. by advising on EIA legislation or by capacity building). The aims of these interventions are environmental protection in concrete cases and enforcing the institutionalisation of environmental protection, respectively. Learning by actors involved is an important condition for realising these aims. A relatively underexplored form of learning concerns learning at EIA system-level via project level donor interventions. This ‘indirect’ learning potentially results in system changes that better fit the specific context(s) and hence contribute to higher performances. Our exploratory research in Ghana and the Maldives shows that thus far, ‘indirect’ learning only occurs incidentally and that donors play a modest role in promoting it. Barriers to indirect learning are related to the institutional context rather than to individual characteristics. Moreover, ‘indirect’ learning seems to flourish best in large projects where donors achieved a position of influence that they can use to evoke reflection upon system malfunctions. In order to enhance learning at all levels donors should thereby present the outcomes of the intervention elaborately (i.e. discuss the outcomes with a large audience), include practical suggestions about post-EIS activities such as monitoring procedures and enforcement options and stimulate the use of their advisory reports to generate organisational memory and ensure a better information dissemination.     

Sustainability assessment of national rural water supply program in Tanzania

Sustainability of rural water supply programs in developing countries is still an elusive goal. It is widely accepted that, as a rule, they have failed to deliver benefits to society in the long run. Emphasis has frequently been placed on the short‐term activities. Fast production of new schemes is thus a common strategy, prioritizing the engineering component, while sidestepping social and participatory issues and community empowerment. In 2006, the Government of Tanzania launched a national program to meet water sector targets set out in the Millennium Development Goals by the year 2015. In this study we evaluate key features of the program on a sustained basis. There is evidence that the Government is promoting more sustained facilities, focusing on cost recovery and on ‘decentralization by devolution’. Nevertheless, there are several shortcomings which threaten the long‐term functionality of the infrastructure that has to be built. In light of the implementation of the program, and based on the outputs of its pilot phase, we review the factors that can determine its sustainability.     

The Impact of Scientific Information on Ecosystem Management: Making Sense of the Contextual Gap Between Information Providers and Decision Makers

Scientific information is not always effectively incorporated into decision-making processes. This phenomenon seems to hold even when the information is aligned with an articulated need, is generated according to sound scientific procedures, and is packaged with end-user preferences in mind. We propose that contextual or cultural differences contribute significantly to the misalignment in communication between those who generate information and those who seek information for improved management of natural resources. The solution is to cultivate shared understanding, which in turn relies on acknowledgment and sharing of diverse values and attitudes. This constitutes a difficult challenge in a culturally diverse environment. Whereas cultural diversity represents wealth in experiences, knowledge and perspectives it can constrain the potential to develop the shared understandings necessary for effective integration of new information. This article illustrates how a lack of shared understanding among participants engaged in a resource-management process can produce and perpetuate divergent views of the world, to the extent that information and knowledge flows are ineffective and scientific information, even when requested, cannot be used effectively. Four themes were distilled from interviews with management and scientific staff of a natural resource–management agency in South Africa. The themes are used to illustrate how divergent views embedded in different cultures can discourage alignment of effort toward a common purpose. The article then presents a sense-making framework to illustrate the potential for developing shared understandings in a culturally diverse world.