Citation

Stemn E, Hassall ME, Bofinger C. Safety Sci. 2020; 123: e104565.

Copyright

(Copyright © 2020, Elsevier Publishing)

DOI

10.1016/j.ssci.2019.104565

PMID

unavailable

Abstract

Learning from incidents is regarded as a key component of an organisation's safety management system and an important means of improving organisational safety. However, several factors could affect the effectiveness of the learning process. In this study, our focus is to identify the constraints impeding effective learning from incidents in Ghanaian mines, including factors emanating from outside an organisation and determine associations and possible cause-effect links between these constraints. We interviewed 41 incident investigators and 8 victims across five large-scale gold mines in Ghana and analysed the data through qualitative content analysis, correspondence analysis and AcciMap. We identified 45 specific constraints grouped across five levels of a sociotechnical system that affected the effectiveness of the learning process. Many of the factors were independent of the investigators and victims and were organisational, regulatory and societal. Through correspondence analysis, we observed strong associations among the constraints. Specifically, constraints at the organisational, work and regulatory levels were strongly associated. The AcciMap method of accident analysis was used in depicting the systemic nature and establishing cause-effect relationships between the constraints both within and across levels. As constraints at the upper levels influence those at the lower level, it would be inappropriate to focus improvement measures on individual factors without addressing the main problems at the organisational, regulatory and societal levels. Therefore, specific measures have been recommended at all the five levels to promote the effectiveness of learning from incidents at the mines.

Language: en

Keywords

AcciMap; Correspondence analysis; Incident investigation; Sociotechnical system; Systemic constraints