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Experience feedback Sociocultural success factors

Industrial firms have been using experience feedback and lessons learned analysis for many years. How can they develop a reporting culture; how to avoid complacency at all hierarchical levels?

Objectives

Operational experience feedback (OEF), or lessons learned analysis (the terminology used is industry-dependent) is an essential process implemented by most firms with high-hazard activities. There is widespread agreement on the benefits of methodically learning the lessons from events (incidents, quasi-accidents, accidents, deviations from procedure, etc.) that had or could have had a safety impact. However, putting it into practice is often complicated:

  • Tensions, conflicts, and crises can be caused by OEF (both internally, because of problems that arise when the blame for certain errors or mistakes is pinned on specific individuals or groups; and externally, given the way in which various players - the courts, the media, NGOs, regulators, expert agencies, competitor companies and insurers can use the results of investigations to their own ends.
  • Of the difficulty in developing a global approach to OEF taking into consideration both technical aspects and human and organizational aspects (integrating dimensions that are harder to measure and quantify);
  • Of the difficulty in designing OEF procedures that enable true feedback (in terms of action and organisation);
  • Of the difficulty in maintaining the foundational sustainability of feedback, in stabilizing and adapting devices and structures that ensure its implementation (because of the problem created by a permanent and long-lasting mobilization, around the questions of safety);
  • Of the difficulty in organizing experience sharing beyond the companies directly involved (with subcontractors; with other companies from the same industry sector; with regulators and their technical support organizations, with NGOs and local stakeholders).

Research programme

This was the topic of a working group hosted by ICSI in 2004 in order to foster mutually beneficial information amongst companies from diverse business sectors.

It then gave rise to a call for research proposals published by Foncsi in 2005, which led to 8 projects (among which 7 doctoral theses) being funded. The researchers worked in various industrial contexts: steel, energy, nuclear power, refining, chemical, pharmacology production, transport.

In the end, a research results transfer group, hosted by Foncsi, gathered industry experts, supervisory authorities and labor unions, in order to help firms with high-hazard activities improve their OEF processes.

> Full text of call for proposals

The Research projects

> Feedback and industrial safety: learning dynamics in networked industrial systems, team of Stéphanie Tillement, Thomas Réverdy et Céline Cholez, laboratoire PACTE (Université de Grenoble)

> Consideration of weak signals in safety management: diagnosis on a refinery and a steel manufacturing site, with Ève Guillaume (PhD student, TUDelft), Floor Koornneef (TUDelft), Andrew Hale (TUDelft), Yves Dien (EDF R&D), Jean-Christophe Le Coze (INERIS) and Nicolas Dechy (INERIS).

> Experience feedback and naive explanations?: study in the sectors of the chemistry and nuclear power, team of Safiétou Mbaye (PhD student, Université de Grenoble), Rémi Kouabenan (Université de Grenoble) and Philippe Sarnin (Université de Lyon).

> Feedback and risk management information system : integration of experiential data, team of Céline Tea (PhD student, ENSAM) and Bertrand Munier (GRID, ENSAM/ESTP).

> Safety in European air transport: preconceived ideas and new approaches, team of Kyla Zimmermann (née Steele, PhD student at CNAM), Jean Pariès (Dédale) and René Amalberti (IMASSA).

> Weak signal insertion in a pharmaceutical company's HSE management system, team of Ambre Brizon (PhD student, Ecole des Mines de Paris), Jean-Luc Wybo (École des Mines de Paris) and Marc Poumadère (Symlog).

> Organizational reliability and pairings: the case of co-conception in a complex company, team of Colin Lalouette (PhD student, Université de Toulouse), Bernard Pavard (Université de Toulouse) et Jean-Marie Jacques (Université de Namur).

> Feedback: a way of opening up companies to the public arena, team of Patrick Chaskiel (Université de Toulouse), Eric Chauvier (Université de Bordeaux), Irène Gaillard (IPST-CNAM) and Alain Garrigou (Université de Bordeaux).