Supporting the transfer of knowledge in high-risk major accident environment

A key element in learning from accidents is the skill associated with the transfer of knowledge gained by the operator from historical incidents. These incidents can include accidents and near-misses that occurred on site or in similar companies outside the plant. Knowledge transfer within the enterprise can be supported by a suitable framework or model that is easily understood by a wide range of people who are interested in the lessons learned from accidents. The application of some of the knowledge transfer models used so far can be quite time consuming and uncomfortable for the participants. For this reason, this paper aims to propose a simple model designed to support knowledge transfer. This model is proposed based on the widely used PDCA (plan-do-check-act) framework. Its use is demonstrated by the case of a major accident that occurred in the Czech Republic. The model can be used not only for learning from major accidents that occur in the subject company but also for learning from near-misses or events that occurred in the past in similar plants. Thus, the model can easily help in increasing the efficiency of the accident-learning system in particular.