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Improving incident reports in the swedish armed forces
Swedish National Defence College, Department of Military Studies, Command & Control Studies Division.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

It is generally maintained that learning should be a part of the daily routines of many organizations; this is often referred to as lesson learned processes. The purpose of organizational learning is to foster improvements that seek to both reduce incidents and accidents and reduce their consequences when they nevertheless happen. Safety work is widespread among many organizations, e.g. aviation, hospitals, process industry, fire departments and several armed forces. A considerable part of safety work involves accident prevention, and aims to investigate why and how previous accidents and incidents happened, in order to learn how to avoid them, or minimize losses when they do occur. The collection of information after incidents represents one of the first steps in a lessons learned process, and the result is crucial for further work. Unfortunately, incident reports often tend to be unfocused (they represent a very wide area of issues) and, for that reason, cannot be clustered. They also frequently lack by analysts required information. The overall research objective in this thesis was to develop a report structure that enables the individuals who participated in or observed an incident to provide more information that is relevant about that incident. The first research question seeks to identify whether the Swedish Armed Forces face the kinds of problems that have been identified in earlier research on attempts to learn from accidents and incidents. The second and third research questions aim to ascertain whether the scope and quality of collected information in incident reports can be improved and if the number of incident reports can be increased. The results agree with earlier research and show that many of the problems that are common in other organizations (e.g. aviation, hospitals and the process industry) can also be observed and are a reality within the SwAF. In addition, the results showed that both scope and quality of collected information can be influenced. Group reporting using a consensus process neither had an appreciable effect on the quality of collected information, nor on the quantity of the reports. On the other hand, the new reporting form, which was based on interview and questionnaire methodology, and to some extent witness psychology, significantly improved the quality of the information collected after incidents. The new form proved to be superior, regardless of the character and context of the incidents. The information collected was also in accordance with what had actually happened and, finally, the form proved to be useful when various military “real world” incidents were reported. Finally, the results also provide new insights into the problems and possibilities associated with acquiring useful incident reports. The problem seems not only to be that people may be unwilling to report incidents that they have participated in or witnessed; it is also that they may be unable to do so. Consequently, it may not be sufficient to change the culture of the organization into a learning culture to receive by analysts required information. It is also necessary to help people report what they actually know by means of an improved report structure.

Place, publisher, year, edition, pages
Lund: Department of Fire Safety Engineering and Systems Safety, Faculty of Engineering, Lund University , 2013. , 65 p.
Series
Department of Fire Safety Engineering, Lund Institute of Technology, Lund University, ISSN 1402-3504 ; 1050
Keyword [en]
Incident reports, lessons learned, design science, memory psychology, cued recall, eyewitness testimony
National Category
Engineering and Technology
Research subject
Ledningsvetenskap
Identifiers
URN: urn:nbn:se:fhs:diva-3785ISBN: 9789174734263 (print)OAI: oai:DiVA.org:fhs-3785DiVA: diva2:619217
Available from: 2013-05-02 Created: 2013-05-02 Last updated: 2013-08-16Bibliographically approved
List of papers
1. Success and Failure Factors for KM: The Utilization of Knowledge in the Swedish Armed Forces
Open this publication in new window or tab >>Success and Failure Factors for KM: The Utilization of Knowledge in the Swedish Armed Forces
2009 (English)In: Journal of universal computer science (Online), ISSN 0948-695X, E-ISSN 0948-6968, Vol. 15, no 8, 1735-1743 p.Article in journal (Refereed) Published
Keyword
Knowledge Management, Lessons Learned, Evaluation of Knowledge Management
National Category
Engineering and Technology
Research subject
Ledningsvetenskap
Identifiers
urn:nbn:se:fhs:diva-2218 (URN)
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2013-12-18Bibliographically approved
2. Sharing Knowledge: How to Highlight Proven Experience in the Swedish Armed Forces
Open this publication in new window or tab >>Sharing Knowledge: How to Highlight Proven Experience in the Swedish Armed Forces
2011 (English)In: Journal of Communication and Computer, ISSN 1548-7709, ISSN 1548-7709, Vol. 8, no 5, 410-414 p.Article in journal (Refereed) Published
Place, publisher, year, edition, pages
Libertyville: David Publishing Company, 2011
Keyword
learning organization, knowledge acquisition, experience, knowledge sharing, knowledge utilization.
National Category
Engineering and Technology Social Sciences Interdisciplinary
Research subject
Ledningsvetenskap
Identifiers
urn:nbn:se:fhs:diva-1093 (URN)978-91-633-4715-3 (ISBN)
Conference
6th International Conference on Information Systems for Crisis Response and Management
Available from: 2011-01-17 Created: 2011-01-17 Last updated: 2013-05-02Bibliographically approved
3. Acquisition of Experience-based Knowledge from the Swedish Armed Forces International Missions: A Comparison between Groups and Individuals
Open this publication in new window or tab >>Acquisition of Experience-based Knowledge from the Swedish Armed Forces International Missions: A Comparison between Groups and Individuals
2010 (English)In: Proc to 7th International Conference on Intellectual Capital, Knowledge Management & Organisational Learning, 2010, 360- p.Conference paper, (Refereed)
Abstract [en]

The world is rapidly changing and industrial war has been replaced with "war amongst the people" (Smith 2007, p. 267). Today many armed forces are faced with new responsibilities and are operating in new environments, necessitating a higher ability to identify and implement improvements more rapidly than before (NATO SG, 2008). The Lessons Learned (LL) process helps to suggest solutions to identify shortcomings and facilitates in making positive experiences durable (French Air Forces, 2008). In organizational learning, there is a pronounced need to get hold of important experience, to reduce repetition of mistakes and facilitate for highquality experiences in purpose to improve. Those experiences represent an important input to the LL process, which in the end produces results that will be instilled back into the organisation. A serious weakness in several organizations seems to be that numerous experiences are poorly reported. Unfortunately there is little research conducted in the military field. On the contrary, there is a huge need in several organizations to get a LL-process implemented. This paper will focus on the initial parts in the LL-process, observation, report and some of the early analysis. The aim is to compare group performances with individual performances and ask if groups produce more mature experience-reports than individuals. The study was conducted within the Swedish Armed Forces and all participants were Swedish soldiers earlier deployed on international missions. The participants were asked to report experiences (problems, difficulties) from their assignment, using two different methods. Would method 1, with conditions that facilitate a united effort to generate thoughts and a critical discussion, improve the progress to produce additional or more mature experience reports, compared with individual performances? The results showed that groups produced somewhat higher scaled and more mature reports than individuals. No indication was found that any of the two methods used in the experiment produced an increased number of reports.

National Category
Social Sciences
Research subject
Ledningsvetenskap
Identifiers
urn:nbn:se:fhs:diva-4120 (URN)
Conference
7th International Conference on Intellectual Capital, Knowledge Management & Organisational Learning, November 11-12 2010, Hong Kong, China
Available from: 2013-08-16 Created: 2013-08-16 Last updated: 2013-08-16Bibliographically approved
4. A Form to Collect Incident Report: Learning from incidents in the Swedish Armed Forces
Open this publication in new window or tab >>A Form to Collect Incident Report: Learning from incidents in the Swedish Armed Forces
2013 (English)In: Electronic Journal of Knowledge Management, ISSN 1479-4411, Vol. 11, no 2, 150-157 p.Article in journal (Refereed) Published
Abstract [en]

In the modern business environment a greater number of organizations act worldwide and regularly meet with new cultures and environments. The change calls for a more rapid learning process than previously, in order to adjust to new situations. In order to prevent incidents from recurring, organizations put effort into collecting information after incidents. Learning from experience is often associated with incidents and accidents, however it can also concern positive occurrence. The purpose of the collection is to explore knowledge, analyse what happened and find the root-cause (basic contributions facts and circumstantial conditions) of the incident. If the root-cause is found, the organisation has possibilities to make changes in order to avoid similar incidents and to respond to crises. The collection is regularly done through pre-printed forms, but the reports are seldom sufficient as they often tend to lack vital information. We state, the answers in incident reports are closely related to the form design and the questions arising in the form. To improve the collection method, we designed a structured incident reporting form, using interview and questionnaire research and focused on the aim of the information collection. Our new form was compared to the unstructured form (at present used in the Swedish Armed Forces and NATO) in two experiments. Forty participants from the Swedish National Defence College were recruited to watch film sequences displaying incidents, and in the time that followed report and describe the incident they had observed in writing. The new structured form led to significantly improved results in both experiments. Structured incident reports, with a focus on the customers’ requests, appear to significantly improve after incident reporting. As incident reports become more complete, analysts have an enhanced possibility to find the basic contributing factors and circumstances and there will be a better possibility to learn in the organization and to avoid similar incidents in the future.

Place, publisher, year, edition, pages
Reading UK: Academic Publishing Limited Curtis Farm, 2013
Keyword
Incident report, experience-based, data collection, incident, tacit knowledge, acquiring knowledge
National Category
Social Sciences Interdisciplinary
Research subject
Ledningsvetenskap
Identifiers
urn:nbn:se:fhs:diva-2221 (URN)
Available from: 2011-11-30 Created: 2011-11-30 Last updated: 2015-05-27Bibliographically approved
5. A New Incident Report Form Leads to Improved Foundation for the Lessons Learned Cycle
Open this publication in new window or tab >>A New Incident Report Form Leads to Improved Foundation for the Lessons Learned Cycle
2012 (English)In: International Journal of Information Systems for Crisis Response and Management, ISSN 1937-9390, Vol. 4, no 3, 14-22 p.Article in journal (Refereed) Published
Place, publisher, year, edition, pages
IGI Global: , 2012
National Category
Social Sciences Engineering and Technology
Research subject
Ledningsvetenskap
Identifiers
urn:nbn:se:fhs:diva-3286 (URN)10.4018/IJISCRAM (DOI)
Available from: 2013-01-10 Created: 2013-01-10 Last updated: 2014-04-01Bibliographically approved
6. Hierarchy and Tacit Knowledge in the Swedish Armed Forces; an Organisational Approach
Open this publication in new window or tab >>Hierarchy and Tacit Knowledge in the Swedish Armed Forces; an Organisational Approach
2011 (English)In: ECIC 2011 3rd European Conference on Intellectual Capital / [ed] Geoff Turner and Clemente Minnone, 2011, 328-332 p.Conference paper, (Refereed)
Keyword
Trust, just culture, reporting system, disciplinary action, after-action review
National Category
Social Sciences Interdisciplinary
Research subject
Ledningsvetenskap
Identifiers
urn:nbn:se:fhs:diva-2219 (URN)978-1-906638-94-8 (ISBN)
Conference
The 3rd European Conference on Intellectual Capital held at University of Nicosia, Cyprus 18-19 April 2011
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2013-05-02Bibliographically approved

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