Learning from incidents: Practices at a Scandinavian refinery

This paper reports on a study of practices used to learn from incidents with the aim of improving safety performance in a Scandinavian refinery. Data for the study was collected during five months of fieldwork at the refinery and interviews with 70 refinery employees. In this paper, we examine how managers, engineers and operators at the refinery participated in activities aimed at learning from incidents. Incident learning did not just happen through formal incident management processes, but also through daily work practices. Hence, workplace learning may be an interesting lens through which to examine employee practices to learn from incidents. We found that employees executed learning-related tasks in different ways from formal presentation of reports and risk reducing measures to informal meetings and discussion raising the reflexivity of employees. We conclude this paper with recommendations for learning practices in large-scale industrial environments.