Luboš Kotek


Luboš Kotek

The author studied in the field of safety engineering and defended his doctoral thesis on Safety of Hydrogen Technologies. He has 20 years of experience in the field of risk analysis, and his research career has included the topic of lessons learned from major accidents.

6 October 2023 08:30 - 10:00
Room A

The literature offers different approaches to understanding the process of learning from accidents, so the description of these subparts may vary depending on the author's conception.

1. The Drupsteen et al. model (Drupsteen et al., 2013) The model was developed by a group of authors from TNO based in the Netherlands. The model was built based on the authors' professional judgment, a search of existing lesson-learning systems used in large mainly petrochemical and oil companies, and a literature search. The process is divided into four basic phases: incident investigation and analysis, action planning, intervention, and system evaluation.

2. Littlejohn et al. model (Littlejohn et al., 2017) The lessons learned model was designed based on an analysis of activities at different types of industrial sites to ensure lessons were learned from incidents. Based on these activities, a total of six phases were identified that typically took place in the industrial sites studied reporting, investigation, alerting, information sharing, putting information into context, and implementation of measures.

3. Energy Institute organization model The model was developed by Energy Institute collaborators based on the models by Drupsteen et al. (2013) and the authors (Lukic et al., 2012). The model of the learning process is divided into a total of five phases. - Incident reporting also includes prioritizing which incidents to investigate. - Investigation involving initial fact-finding, information gathering, and subsequent analysis. - Establishing recommendations that should be translated into specific actions, the results of which should be monitored, implemented, and verified. - Broader learning, which includes learning from incidents. - Evaluation of system changes.

4. REAL model (CCPS, 2021) The Recalling Experiences and Applied Learning (REAL) model is a model designed by the staff and associates of the American Institute of Chemical Engineers (AiChE). This model is based on the PDCA (Plan-Do-Check-Act) cycle.

5. Discussion The presented models are designed for learning within industrial enterprises. All models can be considered sequential. Based on a study, it can be argued that learning from an incident within an organization will occur if the organization is able to carry out the following activities effectively: - Collecting incident information. - Analyse incidents. - Extract and contextualize information. - Store information. - Share information. - Make changes. - Evaluate changes made. - Maintain organizational memory.

Brno University of Technology - Brno - N/A - Czech Republic