Introduction
Learning from past accidents is considered to be very important for organisations in order to prevent recurrence. Throughout the safety literature accident investigations are emphasised as a key element in the prevention of accidents – whether it be occupational injuries or disasters (Benner 1975, Kuhlmann 1977, Ferry 1988, Vincoli 1994, Wagenaar and van der Schrier 1997, Kjellén 2000). The aim is to answer the questions “What went wrong?” and “How can this be prevented in future?”. Whenever an accident or ISSUE 1 2003 VOL7 2 incident occurs, i.e., when a mismatch between an expected and an actual outcome is experienced, there is an opportunity for learning (Harms-Ringdahl 1983, Argyris and Schön 1996).
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