NCO a Centre of Excellence

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NCO a Centre of Excellence
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30 minutes

• Some about NCO
• Ideas for the future
• An university course on accident investigation
• Reflections from the workshop in Karlskoga

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NCO a government commission

• In 2001 the Swedish Government tasked the Swedish
  Rescue Services Agency, in collaboration with
  other authorities, organisations and the private
  sector, to establish a National Centre for
  Lessons Learned from Incidents and Accidents the
  NCO.

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The ambition of the government

• is that the NCO should develop into an
  independent cross-sector centre of excellence
  providing access to facts, statistics and
  expertise in order to improve safety work at all
  levels

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The vision of the NCO

• more effective safety work through improved
  common learning from incidents, accidents,
  injuries and damage

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The NCO will

• be an arena for cross-sector cooperation and
  development of competence
• provide an overview and assessment of incident
  and accident trends and safety work
• develop beneficial feedback for lessons learned
  from incidents, accidents and safety work
• and we do things

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Example of booklets on statistics

• for incidents and accidents
• on injuries amongst the elderly in Sweden

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Example of development of competence

• Course on qualified accident investigation
  methodology held in
• collaboration with the Swedish Royal Institute of
  Technology

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Training course on Advanced accident
investigation methodology

• Aim
• Give a deep understanding of event investigation
  as a tool for improving safety and for safety
  management
• Target group
• Experienced investigators or administrators
  involved in investigations
• To day
• 2 courses
• 16 organisations
• 4 Nordic countries

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Main themes

• Framework for accident investigations
• Different investigation methods ( 15)
• Theories for accidents and control
• Overview of sectors and comparisons (state of
  practice)
• Future investigation strategies ( state of
  art)
• Practical work with a number of methods
• Evaluation of different methods
• Accident Investigation Risk Analysis
• Juridical aspects

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EU/JRC, OECD, UNISDR, NCO Joint MeetingSystemic
Risks and Lessons Learnd
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Reflections from the Workshop

• Techniques for data mining
• Trends and tendencies for chemical accidents
• More user-friendly databases
• Moving from learning to look towards looking
  to learn
• Share information across organisations
• Communication tools
• To convert lessons learned to lessons
  implemented
• Exchange of investigation methodologies
• Shift priority from generating and gathering new
  lessons to implementation of measures from
  lessons already learned
• Workshop on Human Factor

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Accidents i Sweden (9 milj. inh.)

• About 2.500 Peoples killd in accidents every year
• About 130.000 persons needs medical care at
  hospital
• About 900.000 persons needs non institutional
  care

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Aspects of Differing Scales and Perspectives
Frequency

Everyday accidents

Common Unusual Rare
individual group society

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We understand life from history

• 97 98
• of all accidents have happend before
• Our opportunities

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How often have you heard or said

• Yes, something similar happened in - - -
• What report? I dont remember seeing that.
• Im sure Ive seen something like this before but
  I cant find a reference to it
• Thanks for the information, but why didnt you
  tell us sooner?

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It has been said that

• disasters happen when decisions are made by
  people who cannot remember what happened last
  time
• those who cannot remember the past are condemned
  to repeat it
• what has happened before will happen again. What
  has been done before will be done again. There is
  nothing new in the whole world
• every incident has been well rehearsed

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Corporate Memory

• To improve a corporate memory
• is a challenge

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Corporate Memory is not

• A file
• An archive
• An expert system
• A procedure
• An individual

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Corporate Memory is

• The ability an organisation has to assess, store,
  access and utilise knowledge
• This knowledge may be stored in file, database,
  library or an individuals memory
• The storage may be internal or external to the
  organisation
• It is driven and effected by people

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Many are involved in grounding for Safety
After Rasmussen, J.

• Barriers between
• the Levels

and sectors
Breaking the Walls
They need feedback to understand the dynamics
and learn when, how and why they should act
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Who need the knowledgeCourse Consequence and
Barrier Model formats
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Aspects of Differing Scales and Perspectives
Frequency

Everyday accidents

Common Unusual Rare
individual group society

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Risk Analyses

• To see what others will see
• and
• Think what others dont think
• (and remember what others have forgotten)
• (My definition on Risk Analyses)

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AcciMap / A Socio-Technical modelling format
Critical event
Direct conseq.
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An AcciMap-exampleSystem Transport of
Dangerous Goods by road
SYSTEM LEVEL
Point in local risk analysis
Tank rupture
Oil spill to ditch
Difficult roadtopography
Vulnerableenvironm.
Trafficintensity
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Welcome to the NCO
www.nco.srv.se nco_at_srv.se Karlskoga Sweden
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Thank You

• Alf Rosberg
• alf.rosberg_at_raddningsverket.se