Learning from Incidents

Many disasters have occurred because organizations have ignored the warning signs of pre-cursor incidents or have failed to learn from the lessons of the past. Risk is inherent in many high technology systems, but society views the benefits of continuing to operate these systems as outweighing the cost of the occasional disaster. Must we continue to live with disasters? Normal accident theory sees accidents as the unwanted but inevitable output of complex systems, while high reliability theory sees accidents as preventable by certain characteristics of the organization. This paper proposes that an incident learning system can provide a bridge between these two theories. By learning from the incidents that inevitably occur in a complex system, an organization can reduce risk and minimize loss. Thus, an organization with an effective incident learning system sustains a process of continuous improvement that allows it to become a high reliability organization over time. Incident learning theory suggests that implementing a system to encourage reporting of more incidents will drive a cycle of continuous organizational improvement that will reduce incident severity and reduce risk of disaster.