Speaker
Description
Learning from incidents (LFI) is an important aspect of reliability and safety management in particle accelerator facilities. While formal processes such as incident reporting, investigations, and corrective actions are well established, informal learning processes including peer discussions, operational experience sharing, and ad hoc coordination also play a significant role during abnormal situations.
This presentation discusses a case study exploring contrasts between formal incident documentation and operational narratives collected through interviews following an incident. Preliminary observations indicate that important aspects of alarm handling, coordination, recovery activities, and adaptive problem-solving were often absent from formal reports despite playing a significant role in incident response and operational recovery.
The contribution aims to encourage discussion on how particle accelerator facilities, or organizations in general, can better integrate formal investigation processes with the informal operational learning that occurs across technical and organizational boundaries during real events.