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Uppföljning av olycksutredningar inom järnvägssektorn - för en övergripande syn över implementering av åtgärder

Nilsson, Kristin LU (2010) In LUTVDG/TVBB--5332--SE VBR920 20102
Risk Management and Safety Engineering (M.Sc.Eng.)
Division of Fire Safety Engineering
Division of Risk Management and Societal Safety
Division of Risk Management and Societal Safety
Abstract
Unexpected events should be seen as an opportunity to learn for increased safety in the future, but many accidents actually happen because of lack of learning. This study focuses on learning in the railway sector based on insight into the current implementation work of the recommendations that follow the Swedish Accident Investigation Board's (SHK) investigations. A content analysis of SHK's recommendations and the subsequent actions showed which type of these that were used in the field and conclusions about learning could be drawn. Furthermore, interviews with the involved key stakeholders gave insight into which view the key actors have of their own role and the role of the other actors in the process and also if the recommendations and... (More)
Unexpected events should be seen as an opportunity to learn for increased safety in the future, but many accidents actually happen because of lack of learning. This study focuses on learning in the railway sector based on insight into the current implementation work of the recommendations that follow the Swedish Accident Investigation Board's (SHK) investigations. A content analysis of SHK's recommendations and the subsequent actions showed which type of these that were used in the field and conclusions about learning could be drawn. Furthermore, interviews with the involved key stakeholders gave insight into which view the key actors have of their own role and the role of the other actors in the process and also if the recommendations and actions used in the field are satisfying. The result shows that many recommendations are observed but most actions are in progress or planned and have therefore not been completed. Furthermore, it appears that differences between SHK's and the Transport Agency's views of SHK's role, and the Transport Agency's sense of inability to affect common rules in the EU, may have a negative impact on learning. The study also reveals that the actors involved mostly focus on their own business and do not see themselves as a link in the chain of learning from experiences. SHK and the Transport Agency should adopt a more overall view, coupled with good prioritization and responsibility among the operators. These are a few factors that could develop the ability to learn from past events so that they do not happen again. (Less)
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author
Nilsson, Kristin LU
supervisor
organization
course
VBR920 20102
year
type
H2 - Master's Degree (Two Years)
subject
keywords
olycksutredning, rekommendation, åtgärd, implementera, innehållsanalys, klassificering, järnväg, Transportstyrelsen, olycka, Statens haverikommission, tillbud, Banverket, Trafikverket
publication/series
LUTVDG/TVBB--5332--SE
report number
5332
ISSN
1402-3504
language
Swedish
id
1712379
date added to LUP
2010-11-03 09:38:22
date last changed
2020-12-03 14:26:06
@misc{1712379,
  abstract     = {Unexpected events should be seen as an opportunity to learn for increased safety in the future, but many accidents actually happen because of lack of learning. This study focuses on learning in the railway sector based on insight into the current implementation work of the recommendations that follow the Swedish Accident Investigation Board's (SHK) investigations. A content analysis of SHK's recommendations and the subsequent actions showed which type of these that were used in the field and conclusions about learning could be drawn. Furthermore, interviews with the involved key stakeholders gave insight into which view the key actors have of their own role and the role of the other actors in the process and also if the recommendations and actions used in the field are satisfying. The result shows that many recommendations are observed but most actions are in progress or planned and have therefore not been completed. Furthermore, it appears that differences between SHK's and the Transport Agency's views of SHK's role, and the Transport Agency's sense of inability to affect common rules in the EU, may have a negative impact on learning. The study also reveals that the actors involved mostly focus on their own business and do not see themselves as a link in the chain of learning from experiences. SHK and the Transport Agency should adopt a more overall view, coupled with good prioritization and responsibility among the operators. These are a few factors that could develop the ability to learn from past events so that they do not happen again.},
  author       = {Nilsson, Kristin},
  issn         = {1402-3504},
  keyword      = {olycksutredning,rekommendation,åtgärd,implementera,innehållsanalys,klassificering,järnväg,Transportstyrelsen,olycka,Statens haverikommission,tillbud,Banverket,Trafikverket},
  language     = {swe},
  note         = {Student Paper},
  series       = {LUTVDG/TVBB--5332--SE},
  title        = {Uppföljning av olycksutredningar inom järnvägssektorn - för en övergripande syn över implementering av åtgärder},
  year         = {2010},
}