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Are lessons learned from accidents and are potential improvements implemented ?

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Abstract

Current operating feedback Systems (le. systematic and organised analysis of events related either to process malfunction or to industrial safety) in industry show some limits as, in numerous industrial companies, the numbers of events do not significantly decrease anymore and as similar events seem to recur. Despite their recognition as one of the main cornerstones for safety, one can wonder if lessons from both incidents and major accidents are or were satisfactory learned and implemented. These difficulties lead some companies to particularly poorly react to signs that herald an accident. In this paper, we will address several cases in varions high-risk industries that highlighted some failures in their operating feedback Systems. After ïdentifying some of their organisational weaknesses, we will argue about what we assume is foundation of this flaw: the lack of "culture of accidents ".
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ineris-00970482 , version 1 (02-04-2014)

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Michel Llory, Yves Dien, Sandrine Pierlot, Nicolas Dechy. Are lessons learned from accidents and are potential improvements implemented ?. 36. ESReDA seminar, Jun 2009, Coimbra, Portugal. ⟨ineris-00970482⟩

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