“The gift of failure: New approaches to analyzing and learning from events and near-misses.” Honoring the contributions of Bernhard Wilpert

Safety Science(2011)

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摘要
This special issue presents papers from a workshop conducted by New Technologies and Work (NeTWork) to honor the memory of Bernhard Wilpert, the founder and organiser of NeTWork. The papers reflect the theme that undesirable incidents and events, serious and disturbing as they may be, are a “gift of failure.” In short, events offer an opportunity to learn about safe and unsafe operations, generate productive conversations across engaged stakeholders, and bring about beneficial changes to technology, organization, and mental models (understanding). Papers in the special issue are organised around three topics: the process of event analysis, the relationship between event analysis and organisational learning, and learning at multiple system levels. In this introduction we describe the workshop, summarize the contributions of Bernhard Wilpert, suggest three themes that emerged from the workshop, and offer our thoughts about the future of event analysis and learning from events.
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关键词
Event analysis,Learning from events,Safety management
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