how organisations

7/31/2019 How Organisations

1/24

Journal of Workplace LearningEmerald Article: How organisations learn from safety incidents: amultifaceted problem

Dane Lukic, Anoush Margaryan, Allison Littlejohn

Article information:

To cite this document: Dane Lukic, Anoush Margaryan, Allison Littlejohn, (2010),"How organisations learn from safety incidents: a

multifaceted problem", Journal of Workplace Learning, Vol. 22 Iss: 7 pp. 428 - 450

Permanent link to this document:

http://dx.doi.org/10.1108/13665621011071109

Downloaded on: 18-10-2012

References: This document contains references to 48 other documents

Citations: This document has been cited by 1 other documents

To copy this document: [email protected]

Users who downloaded this Article also downloaded: *

Dee W. Edington, Alyssa B. Schultz, (2008),"The total value of health: a review of literature", International Journal of

Workplace Health Management, Vol. 1 Iss: 1 pp. 8 - 19

http://dx.doi.org/10.1108/17538350810865569

Hui Chen, Miguel Baptista Nunes, Lihong Zhou, Guo Chao Peng, (2011),"Expanding the concept of requirements traceability: The rol

of electronic records management in gathering evidence of crucial communications and negotiations", Aslib Proceedings, Vol. 63

ss: 2 pp. 168 - 187

http://dx.doi.org/10.1108/00012531111135646

Charles Inskip, Andy MacFarlane, Pauline Rafferty, (2010),"Organising music for movies", Aslib Proceedings, Vol. 62 Iss: 4 pp.

489 - 501

http://dx.doi.org/10.1108/00012531011074726

Access to this document was granted through an Emerald subscription provided by UNIVERSITI MALAYSIA SARAWAK

For Authors:

f you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service.

nformation about how to choose which publication to write for and submission guidelines are available for all. Please visit

www.emeraldinsight.com/authors for more information.

About Emerald www.emeraldinsight.com

With over forty years' experience, Emerald Group Publishing is a leading independent publisher of global research with impact in


2/24

How organisations learn fromsafety incidents: a multifaceted

problemDane Lukic, Anoush Margaryan and Allison Littlejohn

Caledonian Academy, Glasgow Caledonian University, Glasgow, UK

Abstract

Purpose This paper seeks to review current approaches to learning from health and safetyincidents in the workplace. The aim of the paper is to identify the diversity of approaches and analysethem in terms of learning aspects.

Design/methodology/approach A literature review was conducted searching for termsincident/accident/near misses/disaster/crisis modified with learning/training and safety. Shortlistedarticles were analysed by questioning who is learning, what kind of learning process is undertaken,what type of knowledge is employed and the type of problem that these incidents addressed. Currentapproaches to learning from incidents were critically analysed and gaps identified.

Findings Very few papers addressed all the envisaged aspects when developing their learningfrom incidents approaches. With support from literature, it was concluded that all the fourperspectives, namely participants of learning (participation and inclusion),learningprocess (single loop,double learning), type of incident and its relation to learning (Cynefin complexity framework) andtypes of knowledge (conceptual, procedural, dispositional and locative) are important when deciding on

an appropriate learning from incidents approach.Research limitations/implications The literature review focused on journal articles andidentified keywords, which might have narrowed the scope. Further research is needed in identifyingways to embed the learning from incidents aspects in the organisation.

Practical implications The framework developed could be useful by safety planners, safetymanagers, human resource managers and researchers in the area of organisational learning and safety.

Originality/value The paper concludes by outlining key questions and proposing a framework thatcouldbe useful in systematicallyanalysingand indentifying effectiveapproaches to learning fromincidents.

Keywords Health and safety, Workplace, Workplace learning

Paper type Research paper

1. IntroductionLearning from health and safety incidents in the workplace is critical for organisations.This has been of particularly high importance following a number of widely publicised

major accidents including the space shuttle disasters, the Piper Alpha oil rig accident(1988), Chernobyl (1986) and more recently Texas City Refinery disaster (2005). Suchincidents receive a great deal of media attention and are damaging to both people andthe organisations in which they work. Learning from incidents provides potentialsolutions to preventing future safety crises by looking back at what has happened andderiving lessons learned and predicting probable future challenges (Bond, 2002).

Incidents are usually a result of a combination of failures, rather than a single event(Sepeda, 2006). They tend to be preceded by precursors, such as near misses andsmall-scale events. Failure to recognise and learn from these early signals often resultin larger incidents (Sanne, 2008; Heinrich, 1931). Paradoxically, with the increased

The current issue and full text archive of this journal is available atwww.emeraldinsight.com/1366-5626.htm

JWL22,7

428

Received 15 February 2010Revised 29 April 2010Accepted 20 May 2010

The Journal of Workplace LearningVol. 22 No. 7, 2010

pp. 428-450q Emerald Group Publishing Limited1366-5626

DOI 10.1108/13665621011071109


3/24

awareness of safety issues and implementation of actions to improve safety, there is anarrowing down of opportunities for direct experiential learning within organisations(Rose, 2004; Kolb, 1984). Further to this, learning from incidents should also includepreparation for dissimilar and unexpected incident. Therefore, there is an urgent need toadopt wider approaches to learning that ensure relevant knowledge is shared withinorganisations and across the industry (Rose, 2004; Kolb, 1984).

Learning from incidents becomes a question of how organisations approach safetyand their attitudes to learning from incidents. There are a variety of approachesand interpretations of learning from incidents in the workplace. It is important tounderstand which elements of these approachesare useful in specific contexts and undertime and cost constraints. An example of an approach to organisational safety culture isthe five-level model in which the highest level of safety is generative, characterised bya deep learningculture (InternationalAssociation of Oiland GasProducers(OGP, 2005)).A generative approach involves individuals scanning their environment and seekingpotentially problematic areas that could be improved by discussing and applying newideas (OGP, 2005). Approaches to learning will be influenced by the nature of theproblem: an incident that could lead to a catastrophic, whole-site failure (such asChernobyl) requires a different approach to one that involves a single individual (such asa fork-lift truck accident).

In a generative organisation, safety culture is present throughout the organisation.Therefore, the objective of learning from incidents is not simply sharing knowledgeabouta specific incident, but ratherto aim for a safety culturewhere learning is a processof continuousknowledge flow. The approachto learning will be influenced by thenature

of the knowledge being shared. Approaches to sharing driving safety information(for example, the requirement in many countries to wear a seatbelt) will require adifferent approachto sharingcomplex diagnostic informationon control room incidents.

Since approaches to learning from incidents are embedded within organisationalstructures, they must reflect existing social interactions and involve all relevant actors.It is important to consider who is involved in learning and what the process of learningwill be for example, will learning be focused on individuals accessing sharedinformation or groups of individuals sharing knowledge. This paper reviews currentapproaches to learning from incidents in the workplace. The principle aim was toidentify the diversity of approaches to learning from incidents and analyse them interms of different aspects of learning from incidents they cover. Four aspects oflearning from incidents emerged from an initial review and refinement of the literature.These four aspects are presented as four key questions that were used to guide thereview and analysis of the literature in order to abstract specific factors that influence

learning from incidents:(1) Who is learning?

(2) What kind of learning process is adopted?

(3) What is the nature of problems causing the incident?

(4) What type of knowledge is involved?

These questions clarify the nature and understanding of learning from incidents. First,consideration of who is involved in learning and how they learn within a social context,in a participatory way, enables exploration of the intersection of individual and social

Safety incidents

429


4/24

learning. The question who is learning highlights the breadth of learning. Second,questioning the nature of the learning process requires exploration of the depth oflearning. This is important because the causes of incidents and elements of safetyculture are often unseen; uncovering these requires deep inquiry and reflection. Third,selection of the appropriate approach to learning depends on understanding of thenature and complexity of the incident rather than the application of general approachesregardless of the context. Fourth, the learning intervention should be informed by thetypes of knowledge that stem from an accurate understanding of the cause of theincident. While the four questions outlined above are unlikely to cover all essentialaspects of learning from incidents, they serve as a useful tool to uncover important

factors in the identification of appropriate approaches. The framework does not claim tobe exhaustivebut, rather, forms thebasis of a toolfor analysis of learning from incidents.

2. Conceptual framework2.1 Who is learning?Learning from incidents in organisations involves a variety of stakeholders.Approaches tolearning assume a range of different perspectives: while some focus on individual learning,others emphasise teams and groups, yet others involve the whole organisation or sector.Thenotionof thebreadth of learning relates to thegeneral nature of organisationallearningin terms of theintersectionof theindividualand thesocialfactors.The relationship betweenan individual and the environment is a long standing debate in psychology andorganisational learning. Theories of organisational learning have either an individual or asocial focus (Elkjaer and Wahlgren, 2006; Elkjaer, 1999; Akkerman et al., 2007). On the one

hand, a number of approaches focus on an individuals acquisition of knowledge. Theseapproaches view learning as occurring in individuals; therefore, organisational learninginvolves transferring individual knowledge across the organisation (Elkjaer, 1999). On theother hand, learning has been viewed as participation within a social context, wherelearning is embedded in the social relations, occurs through participation in practice and isubiquitous (Sfard, 1998; Lave and Wenger, 1991; Elkjaer, 1999). Recent research inorganisational learning has focused on bridging the gap between these two schools ofthought, through concepts such as relational interdependence (Billet, 2006) or boundarycrossing between two socio-genetic understandings of group cognition (Akkerman et al.,2007). Even though the organisations still largely focus on the acquisition metaphor oflearning, there is a growing recognition that the social, participatory aspects (interactionswith other people and the environment) impact learning.

Therefore, two concepts are important when we talk about the participants oflearning from safety incidents: inclusion and participation. In terms of inclusion,

the question is how far reaching are the learning incentives and do they address theindividual, teams or the whole organisation. On one hand, the learning should be as closeas possible to the shop floor and the actual workers to be involved. On the other hand,the higher levels of the organisational hierarchy and management are relevant as well.But it is not just the question of mere numbers of the participants in the learning. Theseapproaches tend to involve a variety of collaborating stakeholders throughout the lifecycleof an incident. It is important that these approaches also take into accountthe levelof their participation in order to support the breadth of learning. Key considerationsinclude the extent to which stakeholders have a say throughout the process and haveopportunity to question organisational and systemic issues.

JWL22,7

430


5/24

2.2 What kind of learning process is adopted?There are a wide variety of approaches to learning from incidents in the literature.Argyris and Schons (1996) two modes of learning (double and single-loop learning) couldprovide a conceptual framework for health and safety learning processes. In this context,single-loop learning includes solutions to errors and mishaps in the organisation bycorrecting the superficial elements of the problem. Examples of single-loop approachesinclude skills trainings, punitive decisions and technical changes. These are quick-fixapproaches that companies use to analyse and learn from incidents. These quick-fixapproaches do not question the underlying assumptions and systemic failures that causeerrors and mishaps.

Double-loop learning is based on open inquiry into deep-rooted causes, systemfailures and values. This mode of learning questions the underlying assumptions oforganisational work (Argyris and Schon, 1996) and aims to change organisationalfactors and culture that often cause incidents (Spear, 2002). In this theory, the mainobstaclefor organisational learning and change is thewin-lose frame of thought whereanything that reveals weakness is covered up to avoid embarrassment. In aiming at asafety culture, the blame game should not be the governing mode of action.

Double-loop learning is not as easy to achieve as it may seem (Argyris and Scho n,1996). In this approach, mental models are expressed as either theories-in-use inferablefrom observing actionsand as espoused theories thatpeople perceive as guiding them intheir actions. These mental models can exist at both an individual and an organisationallevel. There are two models of theories-in-use: Models I and II (Argyris and Schon, 1996).Model I consists of win-lose attitudes and the protection of ego. In this model, actions

are rational, seeking to solve problems while retaining the status quo. Model II is basedon openness, informed decisions and individual responsibility, addressing theorganisational defensive routines.

Argyris and Schons findings suggest that Model I is the most prevalent, however,individuals are often not aware of its presence. While their espoused theories may bedefined in terms of honesty, inquiry or truth, their actions may contradict these values.In order to addressthese contradictions, it is necessary to surface the actual assumptionsand theories that lie behind individuals actions. However, there should be a distinctionbetween developing new insights and acting on the basis of these (Argyris and Schon,1996). Double-loop learning is particularly important because of its ability to surfacelatent and systemic causes thatmight be contributing to incidents at a later stage evenwhen these incidents are seemingly unrelated. Failing to address these systemic issuesmight result in similarincidentscoming back in a different guise. Only when meaningfulinquiry takes place and when governing values and perspectives are altered, it is

possible to claim double-loop learning is taking place. Single-loop processes aremaintained by an incredibly skilled organisational dynamic of self-protection whichactually prevents double-loop learning rather than an unawareness, unfamiliarity withor unskilled use of double-loop processes (Bokeno, 2003). Therefore, the indicators ofdouble-loop learning within an organisation include focus on reflection, criticalexamination of the whole system, openness, trust and exploration of the power relations.

Flood and Romme suggest triple-loop learning which builds upon the previoustheories of singleand double-looplearning (Flood and Romm, 1996). Triple-loop learningdeals with structural elements and attempts to link learning into an integrated systemwhere learning strategies are developed and enacted (Romme and Witteloostuijn, 1999).

Safety incidents

431


6/24

However, for the purpose of this literature review, we will be focusing mainly on singleand double-loop learning. The reason for this is two-fold. First, the triple-loop learning isdifficult to discern from the articles. Second, our concern here is mainly the depth oflearning represented by single/double-loop paradigm.

2.3 What is the nature of problems causing the incidents?While the Argyris and Schon theory allows examination of the ways individualscollectively analyse and learn from incidents, another important factor is the nature ofthe problem. An incident investigation process is essential when deciding on theapproach to learning from incidents such that they do not reoccur and thatgeneral safetylevel is increased within the organisation. Learning can emerge not onlyfrom examiningsimilar types of incidents. Learning should also be positioned to explore future risk andto enable prediction of novel incidents (Lindberg et al., 2010). However, incidentinvestigation does not always reveal the true complexity issues and, therefore, mightlead to implementation of inappropriate models. A model is required to identify thenature of theincident and corresponding learningsolutions thatmight be used. Onesuchmodel is the Cynefin framework (Snowden, 2002) which has been used successfully toaddress areas such as organisational complexity and policy, knowledge management aswell as safety at work (Deloitte, 2009) Within this framework, there are four areas ofcomplexity used for sense making (Figure 1). The first two areas are simple andcomplicated. These are in domain of orderly contexts. The other two are complexand chaotic . These are within the un-orderly domain. Problems may arise whensolutions for orderly cases are applied to un-orderly incidents (Snowden, 2002).

In the Simple domain, cause and effect relationships are clear and solutions tend tobe straightforward, often in the form of best practices that can be captured andshared. One needs to determine the facts, categorise them and use the best-establishedpractice when dealing with a particular problem.

In the Complicated domain, causal relationships are not readily evident. An in-depthanalysis is required to surface the issues. While causes may not be evident at anindividuals level, an efficientsolutionusuallyexists and can be identified by someone elsethrough such in-depth analysis. Solutions in the form of good practices (as opposed tobest practices) are likely to be most effective.

Figure 1.Cynefin complexityframework

Complex

P-S-R

Emergent

practice

Novel

practice

Best

practice

Good

practice

A-S-R S-C-R

S-A-R

Chaotic

Sources: Snowden (2002); web site:

http://en.wikipedia.org/wiki/

File:Cynefin.png

Simple

Complicated

JWL22,7

432


7/24

The Complex domain deals with situations where urgent action is required and in whichthere are intertwining causes and influences. These causes are difficult to determine inaction, but could be surfaced in hindsight. Identifying solutions in the complex domainrequires a shift from fail-safe towards a safe-fail attitude, in which solutions canbe tested.

In the Chaotic domain, incidents are usually unforeseen, with littletime for an in-depthanalysis, since rapid, decisive action is required to mitigate the crisis, aiming to shift thesituation from chaotic to complex.

It is important to apply solutions within the appropriate domain. Trying to applysimple solutions to a complex problem (as many organisational issues are) can be

counterproductive. This is not to say thatsimplesolutions, such as best practices,are notuseful. However, it is clear that safety incidents are deeply related to their context andone-fix solutions may not be effective. The relationship between the type of problem andthe learning approach is particularly relevant for the transferability of knowledge aboutan incident from one context to another. The type of knowledge and information aboutan incident might be relevant to other incidents that are seemingly dissimilar.

2.4 What type of knowledge is involved?The nature and complexity of the incident highlight the gaps that the learningapproach should address. Therefore, it is important to take into account the type ofknowledge required to address the negative event and to prevent future events. Threeforms of knowledge are central to learning: conceptual (propositional), procedural anddispositional.

Conceptual knowledge (knowing why and knowing what) comprises facts,concepts and propositions (Anderson, 1982). It refers to declarative understanding ofsafety issues and incidents. Propositional knowledge about incidents can becharacterised at different levels of depth (Greeno, 1989), ranging from simple factualknowledge (e.g. knowingabout therelevant equipment/process) to understanding how aparticular process works in practice, what procedures must be followed with specificequipment and so on. Deep conceptual knowledge is important because it allowscomplex problem solving through enabling an individual to understand the possiblenature of the problem, and its relationship with other, associated problems.

Procedural knowledge (know-how) comprises techniques and skills that enable oneto enact conceptualknowledge (Anderson, 1982). Proceduralknowledge is classifiedintothree levelsof order (Stevenson, 1991). First-order or specific procedures are employed toachieve specific goals or tasks. These procedures are usually automatically enacted,withoutconsciousthought (for example, how to manage high-pressure notice). However,

first-order procedures are specific to particular tasks and, therefore, cannot help in new,unfamiliar situations. In unfamiliar situations, second-order procedural knowledgebecomes important the ability of individuals to monitor and evaluate selection ofstrategy. In other words, second level, procedural knowledge allows individuals toanticipate what might be required and what steps have to be taken to complete a taskwithout causing health and safety issues. Third-level procedural knowledge is requiredto monitor and organise activities, particularly when individuals are faced with noveltasks/problems in new situations.

Dispositions underpin conceptual and procedural knowledge and compriseattitudes, values, emotions, interests and personal motivations (Perkins et al., 1993).

Safety incidents

433


8/24

Dispositions are instrumental in individuals putting their conceptual and propositionalknowledge into action. Dispositions, including values, beliefs about identity and so on,can have strong implications for health and safety (for example, for vehicle drivers insome countries and cultures, wearing a seat belt may be countercultural and makes themappear uncool). Cultural values, related to organisational culture,national/ethnic cultureand culture of professions, can also have a significant role in workplace health and safety.Cultural values may determine whether an issue is addressed in an in-depth or superficialmanner. For example, if workers are asked constantly to change their practice withoutformulating a clear understanding of the reasons for change, they are likely to treat suchchange on a superficial level, potentially resulting in health and safety incidents.

These three types of knowledge have received significant attention in cognitivepsychology and learning literature. However, there is a fourth type of knowledge knowing where which is less well understood (Nicholls-Nixon, 1997, p. 108). We callthis locative knowledge meta-knowledge about the location and sources of relevantknowledge (people, tools, resources and practices) in the organisation and beyond. Thistypeof knowledge is usually acquired through networking and interactions with others.

In practice, all these types of knowledge are equally important and reinforce eachother. Therefore, from a health and safety learning perspective, all aspects of knowledgeneed to be considered. Most importantly, employees should know where to find theknowledge they need to deal efficiently with safety incidents (IBM Institute for BusinessValue, 2009). Therefore, in addition to the breadth and depth of learning, it is importantto consider the type of problem, as well as aspects of knowledge that are ignored, whenidentifying an appropriate learning approach.

3. MethodologyThe issues outlined above require consideration from an interdisciplinary perspective.Therefore, the literature review was carried out using sources not only within healthand safety, but also in management, social sciences, organisational learning andpsychology. The following databases were used: ABI/INFORM Global, ProQuestSocial Science Journals, PsycINFO, Health and Safety Science Abstracts, ASSIA, RiskAbstracts and ERIC. The search was carried out using two federated search engines:ProQuest and CSA Ilumina. Searches were limited to journal articles published after2000, focusing on peer-reviewed articles, though some non-peer reviewed papers wereincluded if these were considered to be significant for the review.

Search terms were selected from the initial readings related to health and safetyincidents. Relevant keywords included: incident, accident, disaster, crisis, near miss.These terms were modified by adding learning or training and safety. The initial

search yielded 131 articles. Following a scanning of abstracts of these articles, 79 paperswere excluded, either because their focus was on safety and learning in contexts otherthan the workplace, they did not deal with learning approaches, or because they weremagazine and newspapers style publications. The remaining 52 articles were studied indetail. Subsequently, 27 were excluded because learning was not a major focus.

The residual 25 articles formed the basis of the literature review. Articles wereselected according to their relevance to learning from incidents and were analysed, usingthe conceptual framework (Figure 2) as an analytical lens. Contexts ranged from theconstruction and energy industries to aviation and healthcare. The aim was to gathera wide range of data for the review, therefore articles relevant to high-risk workplace

JWL22,7

434


9/24

settings were included (where learning from health and safety incidents were relevant).Concepts of inclusion and participation were adopted in relation to the question ofWho is learning? To address What kind of learning process is undertaken?, theconcept of single and double-loop learning was used (Argyris and Schon, 1996). For thequestion What is the nature of problems causing the incident? the Cynefin complexityframework was applied (Snowden, 2002). Finally, to respond to What type ofknowledge is involved? four types of learning (conceptual, procedural, locative and

dispositions) were employed. Current approaches to learning from incidents wereanalysed critically and gaps identified.

4. Review of literature4.1 Who is learning?Approaches to learning from incidents described in the literature conceptualiseparticipation in learning at three different levels: the individual, the team and theorganisation.

Morris and Moore (2000), for example, highlight a form of counter-factual thinking,which they term as upward and self-directed, which they have used to improve the

Figure 2.Framework for learning

from safety incidents

Cynefyn

complexity

framework

Double vs

single loop

Conceptual,

procedural,

dispositional

and locative

Inclusion

and

participation

What is the

nature of

problems causing

the incident?

What kind of

learning

process is

adopted?

Learning

from

incidents at

workplace

Who is

learning?

What type of

knowledge is

involved?

Safety incidents

435


10/24

practice of airline pilots. In this approach, individual pilots reflect upon specificincidents, exploring how situationsmay havebeen improved. Although this approach isuseful in focusing on the individual and improving individual learning, it may not takeinto account organisational factors that may lead to incidents. Another approach thatfocuses on theindividual is the Janus method (Bond, 2002) which hasbeenused withinthe context of construction engineering. In this approach, engineers construct and shareincident reports using a database. Although knowledge is shared across theorganisation, learning is viewed as individual as it is the engineers role to informthemselves and learn about different incidents, applying this learning to their practice.Other models acknowledge the importance of the organisational and social context.For example, Chapman and Ferfolja (2001) use an approach which involves examinationof individuals imperfect, mental models. Although this model is individually focused itrecognises that the mental models are socially mediated. Rose for example explicitlycriticizes other individual approaches saying that, Fixing individual people andreplacing isolated components provides an apparent low-cost solution to provide safetyrather than addressing the issues that really needs to be addressed (Rose, 2004, p. 468).

Many papers outlined approaches based on collaborative models involving teams ofpeople. Forexample, thebow-tiemodel hasbeen used as a learning tool(Chevreau etal.,2006) in which employees are collaboratively build an overview representation anddetailed schematic picture of incidents (bow-tie representations). According to Bleakley(2006), in hazardous contexts, it is important not only to improve individuals technicalproficiency, but also to analyse how teams function. In his review of incidentinvestigation and learning approaches, Le Coze (2008) describes three types of

approachesto learning from incidents.A theoretical approach involves large groups ofpeople at various levels within the organisation. This method provides an in-depthinvestigation which involves a large commitment of time. In contrast, a commissionedapproach involves only some people in specific areas of the organisation, requiring asmallertime investment.In the management approach, variouslevelsare included butthe process is not as participative as the causal models somewhat impose constraints onreality and different view points are not reflected in them. However, it was notdiscernible from his approach how are these lessons found used later on in the possibleintervention phase. Other articles illustrate the idea of inclusion in directions (bottomand the top of the organisation), emphasising that although the grassroot level isimportant, executive involvement in learning should not be overlooked (Dyreborg andMikkelsen, 2003; Cooke and Rohleder, 2006).

Many articles have stressed not only that the wider audience within the organisationshould be included,but that particular attentionshould be paid to the levelof participation

of people (McElhinney and Heffernan, 2003; Macrae, 2008; Rose, 2004; Naevestad, 2008;Welling et al., 2006; Burke et al., 2006; Naot et al., 2004). An article by Spielholz et al. (2007)on safety trainingand useof informationfromprevious accidents alsofocuses on inclusionof stakeholders in a participative manner, emphasising collaboration amongst theseindividuals. This approach could be viewed as taking a top-down approach, since reportsand training materials are delivered to stakeholders, thereby preventing theirparticipation in any real decision making. Comparing the two cases of learning fromincidents in the context of militaryaviation,Naot etal. (2004) contrast one approachwhich,although involvingstakeholders, is decided by a key figure(in this case a commander) andanother participative approach which involves all stakeholders in a decision-making

JWL22,7

436


11/24

process. Despite its more complex nature, this second, inclusive process was,overall,moreefficient in terms of learning and the incident was not repeated. According to Loud (2004)having employees help develop their own standards and procedures promotes theirinvolvement and buy-in. Welling et al. (2006) cite another inclusive learning approachthat aims to involve stakeholders at alllevels of theorganisation in reaching consensus onincidents that have taken place. Inclusion and participation are viewed as essentialcomponents of learning, encouraging stakeholders to take ownership of safety processes(Cooke and Rohleder, 2006; McElhinney and Heffernan, 2003). A further study by Burkeetal. (2006) concurs that participatory approaches are effective for learningfromincidents.These approaches tend to be the mosttime consumingand expensive. However,long term,

they yield the optimal results. Involving different levels of the organisation throughparticipative approaches that capitalise on collective knowledge are important inchanging safety culture within organisations (Naevestad, 2008).

4.2 What kind of learning process is adopted?In considering the depth of learning, our literature revealed three distinct types ofapproaches: approaches promoting single-loop learning; those that recognise barriers todeep learning embedded in the organisation; and approaches promoting double-looplearning.

4.2.1 Single-loop learning. The majority of papers in this review approached learningas reporting of incidents and sharing of lessons learned (Gordon, 2008; Macrae, 2008;Sepeda, 2006).These approaches assume that forlearningfrom incidents to take place it issufficient to build an incidents database and disseminate information. These approaches

do not question how this information is used and incorporated in practice.Burke et al. (2006) emphasise that reflection and critical examination are

preconditions for effective learning from incidents. Despite this, there is little reference intheir study to reflection being applied to organisational and systemic causes underpinninghuman error. Often, the focus is on immediate causes and consequent solutions thataddress the symptoms rather the causes of incidents or deeper assumptions andbehaviours in the organisational culture. This is also evident in the education of safetyengineers which focuses on human and technical factors rather thanorganisational cultureor systemic dysfunctions (Ferjencik, 2007).

4.2.2 Towards double-loop learning. Sanne (2008) noted discrepancies between, onthe one hand, organisationally promoted attitudes and policies, and, on the other hand,occupational attitudes. This discrepancy leads to individuals on the shop floor usinginformal storytelling rather than formal reporting, to share lessons learned. The practiceof resorting to informal storytelling could be causedby the desireto save face, whereby

individualswould avoid exposing their mistakes to the whole organisation, even thoughthe organisation endorsed a no-blame approach (Argyris and Schon, 1996). This isechoed by Rose (2004, p. 468) who suggested that if a culture of perceived riskminimisation and blame avoidance becomes established in an organization the desire tolearn from incidents is greatly diminished. Other studies examine the protection of egowithin formal incidents reports, demonstrated through the use of defensive rhetoricstrategies (Bleakley, 2006). Other barriers to safety culture change and organisationallearning include ambiguity about incident causation, the politicized environments inwhich incident investigation takes place, the human tendency to cover up mistakes,and the secrecy both within and between competing organizations (Cooke and

Safety incidents

437


12/24

Rohleder, 2006, p. 4). Other problems include over-focusing on technical and humanfactors and simple fixes to more intricate problems as organisational defence routines(Le Coze, 2008; Dyreborg and Mikkelsen, 2003; Loud, 2004). Perrow stresses that causesof incidents are frequently defined by companies as:

[. . .] operator error, faulty design or equipment, lack of attention for safety features, lack ofoperating experience, inadequately trained personnel, failure to use the most advancedtechnology, and systems that are too big, under financed, or poorly run.

(Perrow cited in Le Coze, 2008, p. 138). Morrisand Moore (2000) point out that even in privatecounter-factual thinking, defensiveness leads experts to take downward counter-factual

positionsof being almost right. Sveenetal. (2007) state that theblame-game attitudesof anorganisation can persevere longer than a safety incentive can last; they assume that it takesan average of three months for the effects of an incentive to disappear while negativeexperiences, such as recriminations, linger for on average two years.

4.2.3 Double-loop learning. In addition to acknowledging discrepancies andcontradictions in learning from incidents, some authors propose approaches aimed atbring about much desired but difficult to achieve double-loop learning (Sonnemans et al.,2003). Sonnemans for example examines root-cause analysis models as a form ofdouble-loop process where existing, non-existing and inefficient norms are questioned(2008). However, this approach does not take into consideration the gap betweenorganisational espoused theories and actual theories-in-use, since policies and norms donot always represent the reality (Argyris and Schon, 1996). Naot et al. (2004) propose thatgenuine transparency, integrity, inquiry, issue orientation and accountability areimportant in the implementation of double-loop learning.

Smith andElliott(2007) advocate three related concepts:learningfrom crisis, learningfor crisis and learning as crisis. Learning from crisis includes experiential learning fromreal incidents as well as subsequent reflection on incidents. Learning from crisisanticipatesupcoming incidents and tries to formulate ways to avoid these. The third concept, learningas crisis, represents a period when a learning intervention may create confusion, causingquestioning of underlying assumptions. This may create unstable periods for anorganisation. However, if conducted in an open manner and with critical reflection, thismay trigger deep questioning of organisational norms and culture, resulting intransformative outcomes.

Naevestad (2008) uncovered the contradictions and complexities underlying safetyissues. However, in his view, the complexity of safety incidents necessitates complexapproaches. This may include seemingly opposing solutions that are implemented at thesametime (redundancyof frames of reference).He emphasises the inherentcontradiction

between human error and organisational understanding of incidents and proposes thatbothhuman error and organisational or cultural causes would be valid frames of reference.Double-loop learning can be achieved through reflection on practice where employeeshave to deal with different and sometimes opposing meanings in order to solve complexproblems.

4.3 What is the nature of problems causing the incident?While some articles give a general overview of approaches to learning from incidents,others discuss the types of problems underpinning a specific incident. However, fewpapers explicatethe relationship between thetypeof problem at thecoreof an incident and

JWL22,7

438


13/24

the learning approach. Learning solutions are not dealt with in a context-specific manner,perhaps because the applicability of a particular solution to other situations is notstraightforward. It depends on a range of factors, only some of which canbe gleaned fromincidents reports and lessons shared. Nevertheless, several papers advocate learningfromincident reports, sharing lessons learned (Bond, 2002; Gordon, 2008) or learningfrom narratives (Spielholz et al., 2007).

While it is clear fromthe literature that incidents and near-misses reportsare importantfor learning from incidents, emphasising these as a sole solution could be problematic.Incident databases have been praised as member of the review team a member whohastremendous experienceand a great memory! (Sepeda, 2006, p. 10). The database may

be an invaluable source of information; however, this additional member cannot makesense of this information. People should make sense of the information within a databaseand contextualise it.

Approaches to learning from incidents also tend to focus on the generalisibility ofsolutions, as for example when Ortega and Bisgaard (2000) advocate makingmicro-analysis results applicable to as many different contexts or when Chevreau et al.(2006) advance the bow-tie approach being applied across settings. Such approaches failto take into consideration the limitations of applying the same model in various contexts.The danger is that this could result in attempting to fit the data to a model rather thanthe other way around (Naevestad, 2008). Consequently, overly simplistic solutions may beappliedto complexincidents, as exemplified in the focus on best practices as the ultimategoal of training and education (Spielholz et al., 2007).

Learning from incidents is sometimes oversimplified such that incidents are notunderstood in their full complexity. Naot et al. (2004) argue that one of the reasons for thelow-levellearning from an incident in their study wasa relatively brief process of analysisand an overemphasis on implementation of lessons learned. Cooke and Rohleder (2006)noted thedesire to finda single root cause,sometimes termed rootcause seduction.Loud(2004), while accepting the importance of best practices, points out that employees ownsolutions and ideas for standards development might be more appropriate for learningfrom specific incidents. Dyreborg and Mikkelsen (2003) describe three steps in learningfrom incidents, whereby, only after investigating influencing factors and analysing bothimmediate and root causes, can interventions and true learning take place at all levels ofthe organisation. In this sense, the nature and real causes of incidents directly impactlearning interventions. Other authors propose that a combination of complex and simplesolutions should be used (Naevestad, 2008; Le Coze, 2008).

4.4 What type of knowledge is involved?

The articles reviewed pay little attention to the type of knowledge that is involved inlearning from incidents. Papers tend to focus on learning in general rather than itsspecific content. The general emphasis is on the conceptual and procedural knowledge,rather than dispositional and locative knowledge (Welling et al., 2006; Ferjencik, 2007).These types of knowledge tend to be the focus of the lessons-learned approaches(Gordon, 2008; Macrae, 2008; Sepeda, 2006). While these approaches increase thepotential availability of knowledge, they do not guarantee that this knowledge willbe found and used; neither do they guarantee elimination of knowledgecompartmentalisation (Chapman and Ferfolja, 2001). Nevertheless, they offer somebasis for consideration of locative knowledge, since the databases and lessons learned

Safety incidents

439


14/24

instruments could be a place to look into for knowledge. However, without some form ofintelligent decision-making systems, databases may not be useful for the application ofknowledge during emergency situations, when immediate action is needed.

Dispositional knowledge could be very important for learning from incidents,especially in terms of safety culture. McElhinney and Heffernan (2003) raise theimportance of mindsets and values, as, for example, when advocating a shift from thefocus on punishing the culprit to learning from mistakes. Attitudes of openness andguilt-free approaches are required to encourage individuals to report incidents and to bewilling to learn from them (Rose, 2004; Dyreborg and Mikkelsen, 2003). Cooke andRohleder (2006) emphasise a need to improve employees perception of workplace risks

by challenging their existing dispositions, such as an out of sight, out of mindmentality that may increase the risk of an incident. Naot et al. (2004) offer an example oflearning a new attitude. In this example, a groupof air force pilots devised a new motto the truly professional fighter is a cautious fighter in order to change their behaviourand foster a safer environment.

Finally, Ortega and Bisgaard (2000) suggest successive Pareto analysis which wouldhelp in identifying which particular knowledge the employees are missing. It could beargued that in learning from incidents more attention should be paid to dispositions andlocative knowledge. All four types of knowledge are important in learning fromincidents since they mutually reinforce each other.

5. A framework for learning from safety incidentsFollowing our literature review, we propose a framework for analysing and makinginformed choices on selecting an appropriate approach to learning from incidents(Figure 2).

First, understanding the nature of the problems causing incidents is important forensuring that appropriate solutions are devised and implemented. Second, it isnecessary to understand who is to be included in the process of identifying solutionsand to what extent they should participate in the learning process. Both individual andorganisational aspect should be taken into account. Third, the type of knowledge mustbe considered, paying attention to the balance of conceptual, procedural, dispositionaland locative knowledge. Fourth, the depth of learning (single- or double loop) is critical.Research shows that incidents usually are caused by a mixture of technical, human andorganisational factors, therefore both single- and double-loop learning play animportant role.

These four core elements and related concepts are envisaged as part of a cyclicalrather than a step-by-step process. The fourcomponents influence each other. They alsooverlap to a certain degree. This overlap could be desirable as a form of requisite variety(Weick cited in Naevestad, 2008). This framework aims to view learning from incidents

holistically, in the context of the whole cycle of an incident, rather than a finite step.

6. ConclusionsA number of conclusions can be drawn from this literature review, steered byand developed from the initial theories readings and discussions from the literature. First,learning approaches vary significantly in terms of the inclusion of people, ranging fromindividual to team and organisational approaches (including sectoral dissemination). Inaddition, these approaches involve varying degrees of stakeholder participation andinvolvement. There is a general consensus that, even in situations where learning is at anindividual level, the social context plays an important role. Second, many approaches to

JWL22,7

440


15/24

learning do not take into consideration the nature and complexity of the incident. Manylearning interventions and approaches are assumed to be universally applicable withminor adaptations. However, there is a growing recognition of the relationship betweenthe complexity of the problem and the learning approach (Naevestad, 2008).

Third, approaches to learning usually do not take into consideration the type ofknowledge necessary. Approaches tendto focus on conceptual and procedural knowledge,neglecting dispositional and locative knowledge. There are some examples of approachesthat emphasise dispositional knowledge in the form of values and attitudes relevant tothe safety culture.

Finally, learning process often remains single loop in which only superficial aspects

of causes of incidents are addressed. The literature suggests that double-loop learningreduced the potential for incidents to reoccur. Our literature review suggests thatparticipative learning approaches are useful when dealing with learning fromincidents. Planning learning from incidents requires a good understanding of humanfactors in safety and their social and organisational aspects. Therefore, it is importantto take into consideration the social nature of the problem and individuals perspectivesto engage relevant stakeholders, which is the central facet of double-loop learning.

We propose a learning from incidents framework (Figure 2) that could be useful insystematically analysing and indentifying effective approaches to learning fromincidents. This framework could be useful for safety planners, safety managers, humanresource managers and researchers in the area of organisational learning and safety.The framework is unlikely to be exhaustive. However, it serves as a useful tool toanalyse learning from incidents. The scope and effectiveness of the framework will bevalidated in the next phase of research with real-world testbeds and stake-holders.

References

Akkerman, S., Van den Bossche, P., Admiraal, W., Gijselaers, W., Segers, M., Simons, R. andPaul, K. (2007), Reconsidering group cognition: from conceptual confusion to a boundaryarea between cognitive and socio-cultural perspectives?, Educational Research Review,Vol. 2 No. 1, pp. 39-63.

Anderson, J.R. (1982), Acquisition of cognitive skill, Psychological Review, Vol. 89 No. 4,pp. 369-406.

Argyris, C. and Schon, D.A. (1996), Organizational Learning II. Theory Method and Practice,Addison-Wesley, Reading, MA.

Billet, S. (2006), Relational interdependence between social and individual agency in work andworking life, Mind, Culture, and Activity, Vol. 13 No. 1, pp. 53-69.

Bleakley, A. (2006), You are who I say you are: the rhetorical construction of identity in the

operating theatre, Journal of Workplace Learning, Vol. 18 Nos 7/8, p. 414.Bokeno, R.M. (2003), The work of Chris Argyris as critical organization practice, Journal of

Organizational Change Management, Vol. 16 No. 6, p. 633.

Bond, J. (2002), A Janus approach to safety, Process Safety and Environmental Protection,Vol. 80 No. 1, pp. 9-15.

Burke, M.J., Sarpy, S.A., Smith-Crowe, K., Chan-Serafin, S., Salvador, R.O. and Islam, G. (2006),Relative effectiveness of worker safety and health training methods, American Journalof Public Health, Vol. 96 No. 2, p. 315.

Chapman, J.A. and Ferfolja, T. (2001), Fatal flaws: the acquisition of imperfect mental modelsand their use in hazardous situations, Journal of Intellectual Capital, Vol. 2 No. 4, p. 398.

Safety incidents

441


16/24

Chevreau, F.R., Wybo, J.L. and Cauchois, D. (2006), Organizing learning processes on risks byusing the bow-tie representation,Journal of Hazardous Materials,Vol.130No.3,pp.276-83.

Cooke, D.L. and Rohleder, T.R. (2006), Learning from incidents: from normal accidents to highreliability, System Dynamics Review, Vol. 22 No. 3, pp. 213-39.

Deloitte (2009), Mining safety: a business imperative, Thoughts Leadership, Studio at Deloitte,Johannesburg.

Dyreborg, J. and Mikkelsen, K.L. (2003), Evaluation of an accident investigation tool usinga safety perception maturity scale, Safety Science Monitor, Vol. 7 No. 1.

Elkjaer, B. (1999), In search of a social learning theory, in Easterby-Smith, M., Burgoyne, J. and

Araujo, L. (Eds), Organizational Learning and the Learning Organization, Sage, London,pp. 74-91.

Elkjaer, B. and Wahlgren, B. (2006), Organizational learning and workplace learning similarities and differences, in Antonacopoulou, E., Jarvis, P., Andersen, V., Elkjaer, B.and Hyrup, S. (Eds), Learning, Working and Living. Marking the Terrain of Working LifeLiving, Palgrave Macmillan, London, pp. 15-32.

Ferjencik, M. (2007), Best starting point to comprehensive process safety education, ProcessSafety Progress, Vol. 26 No. 3, pp. 195-202.

Flood, R.L. and Romm, N.R.A. (1996), Diversity Management: Triple Loop Learning, Wiley,Chichester.

Gordon, H. (2008), Integrating learning into safety: developing a robust lessons-learnedprogram, Professional Safety, Vol. 53 No. 9, p. 30.

Greeno, J. (1989), Situations, mental models, and generative knowledge, in Kotovsky, D.K.K. (Ed.),Complex Information Processing: The Impact of Herbert A. Simon, Lawrence Erlbaum &

Associates, Hillsdale, NJ.Heinrich, H.W. (1931), Industrial Accident Prevention: A Scientific Approach, McGraw-Hill,

New York, NY.

IBM Institute for Business Value (2009), The Enterprise of the Future: IBM Global CEO Study Telecom Industry Edition, available at: www-935.ibm.com/services/us/index.wss/ibvstudy/gbs/a1031155?cntxta1000065 (accessed 20 January 2010).

Kolb, D.A. (1984), Experiential Learning: Experience as the Source of Learning and Development,Prentice-Hall, Englewood Cliffs, NJ.

Lave, J. and Wenger, E. (1991), Situated Learning: Legitimate Peripheral Participation,Cambridge University Press, Cambridge.

Le Coze, J. (2008), Disasters and organisations: from lessons learnt to theorising, Safety Science,Vol. 46 No. 1, pp. 132-49.

Lindberg, A., Hansson, S.O. and Rollenhagen, C. (2010), Learning from accidents what more do

we need to know?, Safety Science, Vol. 48 No. 6, pp. 714-21.Loud, J.J. (2004), Corrective action programs, Professional Safety, Vol. 49 No. 12, p. 32.

McElhinney, J. and Heffernan, O. (2003), Using clinical risk management as a means ofenhancing patient safety: the Irish experience, International Journal of Health CareQuality Assurance, Vol. 16 Nos 2/3, p. 90.

Macrae, C. (2008), Learning from patient safety incidents: creating participative risk, Health,Risk & Society, Vol. 10 No. 1, p. 53.

Morris, M. and Moore, P.C. (2000), The lessons we (dont) learn: counterfactual thinking andorganizational accountability after a close call, Administrative Science Quarterly, Vol. 45No. 4, p. 737.

JWL22,7

442


17/24

Naevestad, T. (2008), Safety cultural preconditions for organizational learning in high-riskorganizations, Journal of Contingencies and Crisis Management, Vol. 16 No. 3, pp. 154-63.

Naot, Y.B., Lipshitz, R. and Popper, M. (2004), Discerning the quality of organizationallearning, Management Learning, Vol. 35 No. 4, pp. 451-72.

Nicholls-Nixon, C.L. (1997), Commentary: the importance of know-where and know-when,in Walsh, J.P. and Huff, A.S. (Eds), Advances in Strategic Management, Vol. 14, JAI Press,Greenwich, CT, pp. 103-9.

OGP (2005), Human factors [. . .] a means of improving HSE performance, InternationalAssociation of Oil and Gas Producers, available at: www.ogp.org.uk/pubs/368.pdf(accessed 20 January 2010).

Ortega, I. and Bisgaard, S. (2000), Quality improvement in the construction industry:three systematic approaches, Total Quality Management, Vol. 11 No. 4, p. 383.

Perkins, D.N., Jay, E. and Tishman, S. (1993), Beyond abilities: a dispositional theory ofthinking, The Merrill-Palmer Quarterly, Vol. 39, pp. 1-21.

Romme, A.G.L. and Witteloostuijn, A.V. (1999), Circular organizing and triple loop learning,Journal of Organizational Change Management, Vol. 12 No. 5, pp. 439-54.

Rose, A. (2004), Free lessons in aviation safety, Aircraft Engineering & Aerospace Technology,Vol. 76 No. 5, pp. 467-71.

Sanne, J.M. (2008), Incident reporting or storytelling? Competing schemes in a safety-critical andhazardous work setting, Safety Science, Vol. 46 No. 8, pp. 1205-22.

Sepeda, A.L. (2006), Lessons learned from process incident databases and the process safetyincident database (PSID) approach sponsored by the center for chemical process safety,Journal of Hazardous Materials, Vol. 130 Nos 1-2, pp. 9-14.

Sfard, A. (1998), On two metaphors for learning and the dangers of choosing just one,Educational Researcher, Vol. 27 No. 2, pp. 4-13.

Smith, D. and Elliott, D. (2007), Exploring the barriers to learning from crisis: organizationallearning and crisis, Management Learning, Vol. 38 No. 5, p. 519.

Snowden, D. (2002), Complex acts of knowing: paradox and descriptive self-awareness,Journal of Knowledge Management, Vol. 6 No. 2, pp. 100-11.

Sonnemans, P.J.M., Koervers, P.M.W., Brombacher, A.C., van Beek, P.C. and Reinders, J.E.A. (2003),Accidents, often the result of an uncontrolled business process a study in the (Dutch)chemical industry, Quality and Reliability Engineering International, Vol. 19 No.3, pp. 183-96.

Spear, J.E. (2002), Incident investigation: a problem-solving process, Professional Safety, Vol. 47No. 4, p. 25.

Spielholz, P., Clark, R. and Sjostrom, T. (2007), Fatality narratives, Professional Safety, Vol. 52No. 4, p. 22.

Stevenson, J.C. (1991), Cognitive structures for the teaching of adaptability in vocationaleducation, in Evans, G. (Ed.), Learning and Teaching Cognitive Skills, Acer, Hawthorn.

Sveen, F., Rich, E. and Jager, M. (2007), Overcoming organizational challenges to secureknowledge management, Information Systems Frontiers, Vol. 9 No. 5, p. 481.

Welling, L., Boers, M., Mackie, D.P., Patka, P., Bierens, J.J.L.M., Luitse, J.S.K. and Kreis, R.W.(2006), A consensus process on management of major burns accidents, Journal of HealthOrganization and Management, Vol. 20 No. 3, p. 243.

Safety incidents

443


18/24

Appendix

Authorandtitle

Journal

Participantsof

learning

Learningprocess

Typeofproblem

Typeofknowledge

1.Bond(2002)AJanus

approachtosafety

ProcessSafetyand

E

nvironmental

Protection

Individual

Singleloop

Usingonlysimpleand

complicateddomain

learningsolutionsand

bestpracticeslearning

Conceptual,

proceduralandsome

locative

2.Bleakley(2006),You

arewhoIsayyouare:

therhetorical

constructionofidentity

intheoperatingtheatre

JournalofWorkplace

Learning

Team

Acknowledging

double-loop

learningissues

Doesnotaddressthe

issue

Procedural,

dispositional

3.Burkeetal.(2006),

Relativeeffectivenessof

workersafetyandhealth

trainingmethods

A

mericanJournalof

PublicHealth

Organisationand

participative

Singleloop

Doesnotaddressthe

issue

Conceptualand

procedural

4.ChapmanandFerfolja

(2001)Fatalflaws:the

acquisitionofimperfect

mentalmodelsandtheir

useinhazardous

situations

JournalofIntellectual

C

apital

Individual

Acknowledging

double-loop

learningissues

Doesnotaddressthe

issue

Conceptual,

proceduralandsome

locative

5.Chevreauetal.(2006),

Organizinglearning

processesonrisksby

usingthebow-tie

representation

JournalofHazardous

M

aterials

Team

Singleloop

Learningapproaches

generisabletoother

typesofproblems

Conceptualand

procedural

6.CookeandRohleder

(2006),Learningfrom

incidents:fromnormal

accidentstohigh

reliability

SystemDynamics

R

eview

Organisation

Acknowledging

double-loop

learningissues

Linkscomplexityof

theproblemandthe

typeoflearning

needed

Conceptual,

proceduraland

dispositional (c

ontinued)

Table AI.Summary of findings

JWL22,7

444


19/24

Authorandtitle

Journal

Participantsof

learning

Learningprocess

Typeofproblem

Typeofknowledge

7.DyreborgandMikkelsen

(2003),Evaluationofan

accidentinvestigation

toolusingasafety

perceptionmaturity

scale

SafetyScience

Monitor

Organisation

Acknowledging

double-loop

learningissues

Linkscomplexityof

theproblemandthe

typeoflearning

needed

Conceptual,

proceduraland

dispositional

8.Ferjencik(2007),Be

st

startingpointto

comprehensiveproce

ss

safetyeducation

ProcessSafety

Progress

Individual/Team

Singleloop

Doesnotaddressthe

issue

Conceptualand

procedural

9.Gordon(2008),

Integratinglearning

intosafety:developin

ga

robustlessons-learne

d

program

ProfessionalSafety

Organisation

Singleloop

Usingonlysimpleand

complicateddomain

learningsolutio

nsand


Conceptual,

proceduralandsome

locative

10.LeCoze(2008),

Disastersand

organisations:from

lessonslearntto

theorising

SafetyScience

(a)theoretical

approach

organisationan

d

participative;

(b)commissioned

approach-some

levels

oforganisation;and

(c)management

approach

organisation

Acknowledging

double-loop

learningissues

Linkscomplexityof

theproblemandthe

typeoflearning

needed

Conceptualand

procedural

11.Loud(2004),Corrective

actionprograms

ProfessionalSafety

Organisationand

participative

Acknowledging

double-loop

learningissues

Linkscomplexityof

theproblemandthe

typeoflearning

needed

Conceptual,

proceduraland

dispositional (c

ontinued)

Table AI.

Safety incidents

445


20/24

Authorandtitle

Journal

Participantsof

learning

Learningprocess

Typeofproblem

Typeofknowledge

12.Macrae(2008),

Learningfrompatient

safetyincidents:

creatingparticipative

risk

Health,Risk&SocietyOrganisationand

participative

Singleloop

Linkscomplexityof

theprobleman

dthe

typeoflearning

needed

Conceptualand

procedural

13.McElhinneyand

Heffernan(2003),Using

clinicalrisk

managementasame

ans

ofenhancingpatient

safety:theIrish

experience

InternationalJournal

ofHealthCareQuality

Assurance

Organisationand

participative

Acknowledging

double-loop

learningissues

Doesnotaddre

ssthe

issue

Conceptual,

proceduraland

dispositional

14.MorrisandMoore

(2000),Thelessons

we

(dont)learn:

counterfactualthinking

andorganizational

accountabilityaftera

closecall

Administrative

ScienceQuarterly

Individual

Acknowledging

double-loop

learningissues

Doesnotaddre

ssthe

issue

Procedural

15.Naevestad(2008),

Safetycultural

preconditionsfor

organizationallearning

inhigh-risk

organizations

Journalof

Contingenciesand

CrisisManagement

Organisationand

participative

Double-loop

learning

Linkscomplexityof

theprobleman

dthe

typeoflearning

needed

Conceptual,

proceduraland

dispositional

16.Naotetal.(2004),

Discerningthequality

oforganizational

learning

Management

Learning

Organisationand

participative

Goingtowards

double-loop

learning

Linkscomplexityof

theprobleman

dthe

typeoflearning

needed

Conceptual,

proceduraland

dispositional (c

ontinued)

Table AI.

JWL22,7

446


21/24

Authorandtitle

Journal

Participantsof

learning

Learningprocess

Typeofproblem

Typeofknowledge

17.Ortegaand

Bisgaard(2000),

Qualityimprovement

intheconstruction

industry:three

systematicapproaches

TotalQuality

Management

Organisation

Singleloop

Learningappro

aches

generisabletoother

typesofproblems

Paretoanalysisfor

decidingwhich

knowledgeisneeded

18.Rose(2004),Free

lessonsinaviation

safety

AircraftEngineering

andAerospace

Technology

Organisationand

participative

Acknowledging

double-loop

learningissues

Linkscomplexityof

theproblemandthe

typeoflearning

needed

Conceptual,

proceduraland

dispositional

19.Sanne(2008),Incide

nt

reportingor

storytelling?competing

schemesinasafety-

criticalandhazardou

s

worksetting

SafetyScience

Team

Acknowledging

double-loop

learningissues

Usingonlysimpleand

complicateddomain

learningsolutio

nsand


Conceptual,

proceduraland

dispositional

20.Sepeda(2006),Lessons

learnedfromprocess

incidentdatabasesand

theprocesssafety

incidentdatabase(PS

ID)

approachsponsored

by

thecenterforchemic

al

processsafety

JournalofHazardous

Materials

Organisation

Singleloop

Usingonlysimpleand

complicateddomain

learningsolutio

nsand


Conceptual,

proceduralandsome

locative

21.SmithandElliott(20

07),

Exploringthebarriers

tolearningfromcrisis:

organizationallearning

andcrisis

Management

Learning

Organisationand

participative

Double-loop

learning

Linkscomplexityof

theproblemandthe

typeoflearning

needed

Conceptualand

procedural (

continued)

Table AI.

Safety incidents

447


22/24

Authorandtitle

Journal

Participantsof

learning

Learningprocess

Typeofproblem

Typeofknowledge

22.Sonnemansetal.(2003),

Accidents,oftenthe

resultofan

uncontrolledbusiness

processastudyin

the

(dutch)chemical

industry

QualityandReliability

Engineering

International

Organisationand

participative

Goingtowards

double-loop

learning

Doesnotaddre

ssthe

issue

Conceptualand

procedural

23.Spielholzetal.(2007),

Fatalitynarratives

ProfessionalSafety

Organisation

Usingonlysimpleand

complicateddomain

learningsolutio

nsand


Conceptualand

procedural

24.Sveenetal.(2007),

Overcoming

organizational

challengestosecure

knowledge

management

InformationSystems

Frontiers

Organisation

Acknowledging

double-loop

learningissues

Doesnotaddre

ssthe

issue

Conceptual,

procedural,

dispositionaland

locative

25.Wellingetal.(2006),

A

consensusprocesson

managementofmajo

r

burnsaccidents

JournalofHealth

Organizationand

Management

Organisationand

participative

Acknowledging

double-loop

learningissues

Doesnotaddre

ssthe

issue

Conceptualand

procedural

Table AI.

JWL22,7

448


23/24

About the authorsDane Lukic is originally from Bosnia and Herzegovina. After finishing his BA in EnglishLanguage and Literature in Belgrade, Serbia, he was awarded an Erasmus Mundus Scholarshipby the European Commission to pursue his European Masters in Lifelong Learning: Policy andManagement, spending his first year at the Danish School of Education in Copenhagen,Denmark, and his second year thesis writing at the University of Deusto, Bilbao, Spain. At theCaledonian Academy, he has undertaken his PhD studies working on the project Learning fromIncidents which is a project aimed at investigating and developing new approaches toenhancing learning from health and safety incidents in the industrial workplace. The PhDFellowship is sponsored by UK Energy Institute and Shell. Besides his research in organizationaland work-based learning, he has experience in non-formal youth learning through EuropeanYouth projects and training courses as well as involvement with youth and studentorganizations. He is an active member of Erasmus Mundus Student and Alumni Association andtook part in the Erasmus Mundus Quality Assurance exercise as a part of the evaluation teamwith the European Commission and ECOTEC Research and Consulting in 2009. His researchinterests include learning processes, organisational learning, innovative learning approaches,training and facilitation, lifelong and lifewide learning and intercultural competence. Dane Lukicis the corresponding author and can be contacted at: [email protected]

Anoush Margaryan is a Lecturer in Learning Technology and Shell Research Fellow at theCaledonian Academy, Glasgow Caledonian University, in the UK. She has been involved inresearch, development and teaching in the area of technology-enhanced learning since 1996.Her interests are mainly in the areas of work-related learning, self-directed and self-regulatedlearning and socio-cultural factors impacting diffusion of technology in education and training.Dr Margaryan was born in 1974. She received her MA in Romance-Germanic Philology fromthe Yerevan State University (Armenia) in 1997, her MSc in Educational and Training SystemsDesign from University of Twente (The Netherlands) in 1998 and her PhD in Educational

Science and Technology from the Faculty of Behavioural Sciences (research group of ProfessorBetty Collis), University of Twente in 2006. Her PhD research was sponsored by Shell EPLearning, Leadership and Development organisation and focused on the development andimplementation of a new model of technology-enhanced work-based learning. The aim of themodel was to support instructors, learning designers and managers in organisations indevising strategy and curriculum for learning; in developing course design, evaluation andassessment processes, and in capturing and sharing good practice in learning within theorganisation. The model was implemented at Shell EP Learning Centre in The Netherlands.Anoush Margaryan has worked within both higher education and corporate learning sectors.Prior to joining Glasgow Caledonian University, she was as an Associate Director and ResearchFellow at the International Centre for Research on Learning at the University of Dundee. Sheheld research and visiting lectureship positions at universities in The Netherlands andGermany, worked as a Research Analyst at Shell EP Learning and Leadership Development,and acted as a Consultant to the World Bank on projects involving use of network technologyto support teacher training. She is a member of the European Association of Research in

Learning and Instruction and co-chairs with Professional Allison Littlejohn the UK HigherEducation Academy national forum on Supporting Sustainable eLearning. Her new bookWork-based Learning: A Blend of Pedagogy and Technology has been recently published byVDM Verlag Dr Mueller.

Allison Littlejohn is the Chair of Learning Technology and Director of the CaledonianAcademy at Glasgow Caledonian University, UK: an academic support centre integratingresearch, advanced scholarship and transformational change in learning innovation. She leads arange of research and learning development initiatives exploring learning innovation. As a ShellSenior Researcher, she is leading an action research partnership between Glasgow CaledonianUniversity and Shell International exploring new approaches to work-based and collectivelearning. In 2003, she published the first international textbook in sustainable e-learning:

Safety incidents

449


24/24

Reusing Online Resources (Routledge, London), published Preparing for Blended eLearning in2007 and co-launched a new book series for Routledge, Connecting with eLearning. As a Fellowand Associate Scholar of the UK Higher Education Academy, she co-chaired the UK Forum onSupporting Sustainable e-Learning (2003-2006). In 2005, she was awarded a scholarship by theAustralasian Learning Technology Organisation ASCILITE. She was previously the Chair ofLearning Technology and Director of the International Centre for Research on Learning atthe University of Dundee, a Senior Lecturer in Academic Practice at the University of Strathclydeand has held academic positions at the Universities of Glasgow, Strathclyde, Thurso College(UK) and the University of Northern Colorado (USA).

JWL22,7

450

To purchase reprints of this article please e-mail: [email protected] visit our web site for further details: www.emeraldinsight.com/reprints

how organisations

Documents