Lärande från brandutredningar : En granskning av åtgärdsförslag i brandutredningar från Storstockholms brandförsvar

In recent years, criticism has been raised against the Swedish fire brigades both from their own staff and from researchers regarding deficiencies in learning and experience feedback within the organizations. Among other things, they have been criticized for that the documentation is only proliferating paper work because there is no system available for deriving advantage from the experience. A researcher who has studied the area is Anna-Karin Lindberg, who reviewed the learning from the fire brigades operating reports. She concludes, among other things, that the spreading of knowledge and lessons learned from the operating reports do not work particularly well. At the Greater Stockholm Fire Brigade there were suspicions that the same problems regarding the operating reports also applied to the fire investigations. We have in this thesis reviewed parts of the process of fire investigations to identify deficiencies, mainly with regard to experience feedback from the suggestions for improvement put forward in fire investigations. The work was conducted in three steps encompassing: 1) analyzing various theoretical models to be used in fire/accident investigations, 2) reviewing fire investigations to examine their coherence with theory, and, 3) reviewing the content, quality and extent of the suggestions for improvement contained in fire investigations. The completed study covers a total of 130 fire investigations, written by Stockholm / the Greater Stockholm Fire Brigade in the years 2006 to 2010. Fire investigations have been reviewed and the various suggestions for improvement have then been indexed in a database. From this database, and through interviews and literature studies, we note that there are deficiencies in the process of experience feedback from fire investigations, mainly referring to the suggestions for improvement which only reach out to a small number of people, both internally and externally. The external distribution is more or less exclusive to the Swedish Civil Contingency Agency (MSB) and the suggestions for improvement that primarily should be handled locally may not be carried out. There are also uncertainties regarding whom or what part of the organization that is responsible for passing on the suggestions for improvement and there is a lack of effective channels for disseminating the information to the most crucial recipients. In conclusion, it is recommended that the Greater Stockholm Fire Brigade: - develops a system for how the suggestions for improvement and experiences best should be handled and pin down which part of the organization that is responsible for communicating them. - customizes the report template so that it aims at concrete suggestions for improvement and introduces a mailing list or something equivalent. - initiate contacts with the most frequent recipients of suggestions for improvement and examines how these should be performed.Validerat; 20110905 (anonymous