Learning from Successful Operations

In this project we have contributed to increased knowledge of why accidents DO NOT happen. We have developed methods and tools that practitioners can use to analyse and learn from successful operations, eg. in the context of investigations, debriefing after demanding operations and education/training. Traditionally, we have been concerned with faults, failures and why things go wrong. This is still an important part of safety management, but there is also much to learn why things are going well. What environmental conditions are important to succeed in managing a demanding operation in a good way? A rich array of methods exists to analyse the causes of accidents and critical events, and great efforts are put into such analyses and dissemination of results by the petroleum industry world-wide and by national authorities. However, there is a scarcity of methods for analysing successful operations. These aspects of safety have received far less attention than the causes of failure. By this project vi have tried to correct some of this shortcoming. The following research questions have been addressed in this project: 1. How can successful operations be distinguished from unsuccessful operations? 2. How do individuals, groups and organisations anticipate, prevent, detect, interpret and handle disturbances that may lead to accidents? 3. Are there systematic differences between successful and unsuccessful operations with regard to planning, preparation and execution? 4. What environmental conditions are conducive to successful operations? (human-machine interface, procedures, skills, collaboration/robust work practices) 5. How can successful operations be analysed and described by practitioners in a way that contributes to improved safety? Dissemination: Project results have been communicated to industry through workshops, seminars and pamphlets. Additionally, there have been publications in scientific journals and presentations at international conferences. Furthermore, the project results have been disseminated through a guide: What do you do when you build safety? - Practitioners' guide to learning from successful operations, and through educational programs organized by ROSS Gemini Centre at NTNU; www.ntnu.edu/ross. The project team has been group of researchers from SINTEF, NTNU and NTNU Social Research. Internationally, we have collaborated with Professor Andrew Hale (Hastam, UK) and Professor Erik Hollnagel (University of Southern Denmark).

Safety, in the sense of accident-free operations, has received less attention from safety scientists than accidents. This applies to theory development and empirical work, and even more to the development of methods and tools to promote learning from expe rience. This project explores how safety is achieved in operations that are more or less successful, that is, situations where accidents and negative concequences do not occur. The overall objective of this project is to develop knowledge and guidelines for improving the learning from operations which do not result in major accidents. An important sub-objective is to identify factors contributing to success in dealing with critical situations, and factors which promote or prevent learning from successfu l operations. The proposed project will provide (1) new scientific approaches to study successful operations, (2) documentation of cases of successful operations that can be used for educational purposes and metaanalysis, (3) new theoretical accounts of successful operations, and (4) methods and guidelines that can be used by companies to analyse and learn from successful operations (e.g. in incident investigations, debriefing and training activities). The knowledge gained from this project will be impo rtant for oil companies in reducing risk of major accidents. Project results will also contribute to improved understanding of operational and organisational barrier elements and application of project findings should improve barrier management in the p etroleum industry. The project will promote the development of relevant educational programmes and other knowledge-disseminating activities.