Learning From Incidents and near Misses – Understanding History to Improve the Future

"Those who cannot remember the past are condemned to repeat it.” This session solicits papers that describe how organizations drive improvements as an output from incidents and near misses. In particular, the desired focus of the session is on how leveraging is done from one facility to another within an organization and how events from general industry are reviewed, disseminated, and improvements driven. Preference will be given to papers that focus on driving down lower on the safety pyramid through robust near miss programs, and those papers that discuss methods to drive learning all the way to the operator/technician level.