Organizational effects of experience from accidents. Learning in the aftermath of the Tretten and à sta train accidents

Our findings indicate that learning from these events was not expressed as an explicit goal in the aftermath. Learning in these cases seems to be linked for a large part to a change in measures, technical, operational and organizational, but we have not observed any managed confirmation or comprehension processes. The Tretten accident report suggests that the possibility of human error should be mitigated through the implementation of technological barriers, while it omits all other elaborations and risk reducing measures. The Åsta accident report recommended that the work to introduce modern safety management principles that had already been initiated before the accident should be continued. Neither of the accidents yielded any new insights and the knowledge brought forward was merely perceived as confirmation of already-agreed changes.