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Three serious accidents occurred in three dynamite manufacturing plants within three European countries during a relatively short time period triggering the question of effective external learning. The article discusses the lessons for the prevention of accidents learned from retrospective comparative analysis. It advocates for a better process for learning lessons. It attempts to show how a two level approach to accident analysis may help to reveal a common deeper learning hidden under diverse routine lessons., Ve třech výrobnách dynamitu ve třech evropských zemích nastaly v průběhu poměrně krátkého časového období tři závažné havárie, což vyvolává otázku po účinném poučování z externích událostí. Článek diskutuje poučení pro prevenci havárií, která jsou výsledkem srovnávací zpětné analýzy. Obhajuje lepší postup vyvozování poučení. Pokouší se ukázat, jak může dvouúrovňový přístup k analýze havárie pomoci odhalit společná hlubší poučení skrytá za rozdílnými rutinními poznatky.

The European Safety Reliability and Data Association (ESReDA) has since 1993 set up a series of Project Groups dealing with the different angles of ‘accident investigation’ and ‘learning from events’. With the 25th Anniversary of ESReDA now in 2016, the core of this group is still active, and has just initiated a new phase with its latest Project Group on ‘Foresight on Safety’. With the objective of improving the quality of accident investigation and the efficiency of learning from experience process and ultimately raising safety performance, the successive groups tasked themselves at two levels: the first one, at a societal, institutional and legal level, on the public accident investigation and societal learning; the second one, at a methodologicaland organisational level, on the conduct of accident investigation, the enablers and barriers to learning. This article summarises the Project Groups' achievements (reports, books, papers and ESReDA seminars) on the various aspects of of accident investigations and dynamic learning from events. This article presents a synthesis of the approach and main results, the lessons learned, some dilemmas and conflicts, future challenges, recommendations and suggestions for action. Although varying in composition over time, the main participants remained involved in the development of the issue: participants from the European and member state authorities, industries, research centres and universities and professional practitioners represent a unique, voluntary cooperation across sectors, actors and disciplines that has lasted for almost 23 years now. At last, with the rise of ‘big data’ it is valuable to recall the interest of single case investigation and address the complementarity of the two approaches to learning., Transport and Planning

The European Safety Reliability and Data Association (ESReDA) has since 1993 set up a series of Project Groups dealing with the different angles of ‘accident investigation’ and ‘learning from events’. With the 25th Anniversary of ESReDA now in 2016, the core of this group is still active, and has just initiated a new phase with its latest Project Group on ‘Foresight on Safety’. With the objective of improving the quality of accident investigation and the efficiency of learning from experience process and ultimately raising safety performance, the successive groups tasked themselves at two levels: the first one, at a societal, institutional and legal level, on the public accident investigation and societal learning; the second one, at a methodologicaland organisational level, on the conduct of accident investigation, the enablers and barriers to learning. This article summarises the Project Groups' achievements (reports, books, papers and ESReDA seminars) on the various aspects of of accident investigations and dynamic learning from events. This article presents a synthesis of the approach and main results, the lessons learned, some dilemmas and conflicts, future challenges, recommendations and suggestions for action. Although varying in composition over time, the main participants remained involved in the development of the issue: participants from the European and member state authorities, industries, research centres and universities and professional practitioners represent a unique, voluntary cooperation across sectors, actors and disciplines that has lasted for almost 23 years now. At last, with the rise of ‘big data’ it is valuable to recall the interest of single case investigation and address the complementarity of the two approaches to learning., Transport and Planning