Improving organisational safety through better learning from incidents and accidents

116 Pages·2014·3.45 MB·English

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Centre for Industrial Production
Aalborg University
ISBN: 978-87-91831-64-5
PhD Thesis, 2014

Improving organisational safety through better
learning from incidents and accidents

Linda Drupsteen-Sint
The Centre for Industrial Production (CIP) was established in 1999 as a part of the Faculty of
Engineering and Science. Since then we have been committed to serve as a national center of
world-class excellence in industrial manufacturing research.
Our mission is to develop and disseminate business engineering knowledge. We accomplish this
by doing application-oriented research addressing current and future challenges in (Danish)
industry. Therefore, we do all our work in close collaboration with our industrial partners and
develop theories based on reality.
CIP is based in both Aalborg and Copenhagen. During the past year CIP has expanded
considerably in Copenhagen and is expected to grow even more the coming years.
In January 2011 CIP merged with Department of Business Studies and formed Department of
Business and Management, which is a cross-faculty department linking together The Faculty of
Social Sciences (Department of Business Studies) and The Faculty of Engineering and Science
(CIP). By bringing together these two faculties the scene is set for an institution with the
professional focus on and strength for rethinking traditional subjects and methods by combining
knowledge about different disciplines.
TTTTiiiittttlllleeee:::: Improving organisational safety through better learning from incidents and accidents
AAAAuuuutttthhhhoooor: Linda Drupsteen- Sint
SSSSuuuuppppeeeerrrrvvvviiiissssoooorrrrssss:
Professor Peter Hasle, CIP/Department of Business and Management, Aalborg University,
Denmark
Professor Gerard I.J.M. Zwetsloot, Nottingham University, United Kingdom & TNO Innovation for
Life, The Netherlands
RRRReeeevvvviiiieeeewwww CCCCoooommmmmmmmiiiitttttttteeeeeeee:
Associate Professor Jan Vang (Chair), CIP/Department of Business and Management, Aalborg
University, Denmark
Associate Professor Heikki Laitinen, Lappeeranta University of Technology, Finland
Associate Professor Kirsten Jørgensen, DTU Management Engineering, Technical University of
Denmark, Denmark
ISBN: 978-87-91831-64-5
Printed by: Ipskamp Drukkers, Enschede, The Netherlands
© Copyright Linda Drupsteen, Centre for Industrial Production (CIP), 2014
All rights reserved. No parts of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without any permission from the author, or when appropriate, from the publishers of the
papers.
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Centre for Industrial Production, Aalborg University

Improving organisational safety through better
learning from incidents and accidents

PhD Thesis, 2014

To be presented for public examination on November 28th 2014 at 10.00
at Aalborg University, A.C. Meyers Vænge 15 | 2450 Copenhagen SV, Denmark

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List of publications
I. Drupsteen L. and Guldenmund F.W. (2014) What is Learning? A Review of Safety
Literature on Learning from Incidents. Journal of Contingencies and Crisis Management,
22 (2), pp. 81 - 96.
II. Drupsteen L., Groeneweg J., Zwetsloot G. I. J. M. (2013) Critical steps in learning from
incidents: Using learning potential in the process from reporting an incident to accident
prevention. International Journal of Occupational Safety and Ergonomics, 19 (1), 63-77.
III. Drupsteen L. and Hasle, P. (in press) Why do organizations not learn from incidents?
Bottlenecks, causes and conditions that create a failure to effectively learn. Accident
Analysis and Prevention.
IV. Drupsteen L. and Wybo, J-L. (in press) Assessing propensity to learn from safety-related
events. Safety Science.
The studies are referenced in the dissertation by their Roman numerals
Other related publications
(cid:127) Drupsteen L., Zwetsloot, G.I.J.M., Groeneweg, J. (2012) Learning from events: a process
approach International Conference on Health, Safety and Environment in Oil and Gas
Exploration and Production, 11-13 September 2012, Perth, Australia.
(cid:127) Drupsteen L., Bos E., Groeneweg J., Zwetsloot G.I.J.M. (2013) Increasing the Learning
Potential from Events: Case studies. Chemical Engineering Transactions 31, 433-438.
(cid:127) Meyer-Larsen N., Drupsteen L., Gräf G., Maier L., Müller R. (2013) Sustainability and
Collaboration in Supply Chain Management: A Comprehensive Insight Into Current
Management Approaches, 16, 221.
(cid:127) Rasmussen H.B., Drupsteen L., Dyreborg J. (2013) Can we use near-miss reports for
accident prevention? A study in the Oil and Gas industry in Denmark. Safety Science
Monitor 17 (2), article 1.

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Acknowledgements ....................................................................................................................................... 6
Summary ........................................................................................................................................................ 7
Dansk Resumé................................................................................................................................................ 9
1. Introduction ......................................................................................................................................... 11
2. Theoretical background ....................................................................................................................... 14
2.1 Incidents ...................................................................................................................................... 14
Incident and accident causes ............................................................................................................... 14
2.2 Defining learning from incidents .................................................................................................. 16
Studies on learning from incidents ...................................................................................................... 16
Safety Management Systems ............................................................................................................... 18
Organisational learning theory ............................................................................................................ 20
2.3 Conditions for learning from incidents ........................................................................................ 22
Studies on hindrances and conditions when learning from incidents ................................................. 23
Conditions for organisational learning ................................................................................................. 24
2.4 Model of the learning from incidents process ............................................................................. 26
Development of the model .................................................................................................................. 26
Assumptions underlying the model of learning from incidents ........................................................... 26
Model of the learning from incidents process ..................................................................................... 27
3. Methods ............................................................................................................................................... 30
3.1 Research design ................................................................................................................................. 30
3.2 Overview of the studies ..................................................................................................................... 30
Study I - What is learning from incidents? ........................................................................................... 31
Study II – Critical steps in learning from incidents ............................................................................... 31
Study III - What are the causes of bottlenecks in learning? ................................................................. 31
Study IV - Assessing the propensity to learn from safety-related events ............................................. 31
3.3 Methods for data collection ............................................................................................................... 32
Qualitative ........................................................................................................................................... 32
Quantitative ......................................................................................................................................... 35
Summary of the research methods ..................................................................................................... 37
4. Findings ................................................................................................................................................ 38
4.1 A model on learning from incidents ............................................................................................. 38
4.2 Difficulties in learning from incidents .......................................................................................... 41
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4.3 Direct causes and underlying factors ........................................................................................... 42
4.4 Conditions for learning ................................................................................................................ 45
5. Discussion ............................................................................................................................................ 46
5.1 Discussing the findings ....................................................................................................................... 46
The learning from incidents process .................................................................................................... 46
Difficulties in learning from incidents .................................................................................................. 46
Underlying causes for ineffective learning ........................................................................................... 47
Conditions for success ......................................................................................................................... 47
5.2 Reflection on the results: towards better learning from incidents .................................................... 48
Diagnosis: knowing what the problem is ............................................................................................. 48
Improving learning from incidents ....................................................................................................... 49
Pitfalls .................................................................................................................................................. 49
5.3 Research limitations ........................................................................................................................... 50
5.4 Implications for research ................................................................................................................... 51
What are the (long- term) effects of an improved learning from incidents process? .......................... 51
How can theories on sharing knowledge contribute to learning from incidents? ............................... 51
How can commitment for learning be triggered? ................................................................................ 51
5.5 Recommendations for practitioners .................................................................................................. 52
6. Conclusion ........................................................................................................................................... 53
References ................................................................................................................................................... 54

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I started this PhD study about five years ago, hoping to gain a more in-depth knowledge to help
organisations prevent accidents and improve safety. While working in the field of occupational
safety, I became more and more convinced that better use could be made of accident
investigations and other available knowledge, and this motivated me to start investigating the
ways in which organisations learn from incidents and accidents.
Performing this study and calling myself a PhD student, created new opportunities: I was able to
join a network of PhD safety students, to attend safety science workshops, to visit many
conferences, and to publish with several inspiring co-authors. In addition, learning from incidents
is a subject that interests many safety practitioners and I am happy that I could collaborate with
them, discuss issues and good examples, and that I am continuously challenged by the
practitioners that should benefit from this research.
In the end I gained much more from this PhD study than just knowledge and skills: I have met
many inspiring colleagues and new friends. It is tempting simply to say: “thanks to all of you, now
let’s get back to normal life” but, this wouldn’t do right by all those people who supported me,
and I have been told that some people find the acknowledgments the only interesting part of
most dissertations.
So, thank you Ageeth, Annemarie, Carlo, Corine, Ingrid, Elisabeth, Elise, Henk&Dien, Janneke,
Hanna, Laura, Mama, Marjolein R. en Marjolein J., Marloes, Martin, Kirsten, Nicolien, Oma, Papa,
Rik, Ruud, Sifra, Shelley and Tialda, for making my life so much more fun in the hours that I am
not working. This hobby took up much of the evenings and weekend, but my friends and family
have never complained, always shown interest and they helped me to keep my feet on the
ground.
Also a huge thank you to Frank Guldenmund, Jean-Luc-Wybo, Victor Roggeveen, Hanna
Rasmussen and the ESReDA project group on learning, for the challenging discussions and the
inspiration. Hanna, I cannot thank you enough for helping me with the summary of my
dissertation.
I’d also like to thank my colleagues at TNO and at CIP. I am proud of the two logos on the front of
this dissertation. They not only represent Aalborg University and my employer TNO, but for me
they represent two groups of inspiring and supporting colleagues who I would like to thank for
that support and for their interest. I would especially like to thank Jop Groeneweg, and my two
supervisors, Gerard Zwetsloot and Peter Hasle. I have doubted many times whether I would be
able to write this dissertation on top of a regular job, but these three men always seemed
convinced that I was capable of doing so. I am lucky to have two supervisors who are so patient
and so constructive in writing their feedback, and a colleague who kicks my arse when necessary.
Gerard was involved in this research from day one, and I could not have found a better
supervisor. Thank you Gerard, for your patience, your support, your ideas, your comments, and
for always taking the time to answer my questions. I would like to thank Jop for challenging me
on my findings and for taking the time to listen when I was about to give up. And Peter, in
addition to thanking you for reading and commenting on all previous versions, thank you for
welcoming me as your PhD student, in the department, and in Denmark.
Last, and most importantly: I could not have done this without Roel. Thank you for bearing with
me, your support means everything to me.
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Learning from incidents is an important aspect of sustaining and improving safety in
organisations. Incidents that have occurred in the past provide valuable lessons for preventing
future incidents. Unfortunately, many organisations fail to successfully learn from incidents, even
when the underlying lessons have been identified. This dissertation addresses this gap by
investigating the main research question: “how can organisations improve their learning from
incidents?”
The research questions in this dissertation are:
(cid:127) How do organisations learn from incidents?
(cid:127) What are the difficulties in learning from incidents in organisations?
(cid:127) What are the underlying factors that make it difficult to learn from incidents in
organisations?
(cid:127) Under what conditions is learning likely to be successful?
In practice, learning from incidents often refers only to the identification of lessons through
incident investigation, and not to the process of improvement that should follow. In this
dissertation, ‘learning from incidents’ refers to an entire process, including the use of lessons
identified for improvement and the evaluation of effectiveness (of the actions for improvement
and of the process itself). By using a model in five phases, based on the Plan-Do-Check-Act cycle,
this dissertation increases insight into the follow-up steps that are necessary for learning
successfully from incidents. The five phases of learning from incidents are: acquiring information,
investigating and analysis, planning interventions, intervening, evaluating. Altogether these
phases of the model of learning from incidents contain 13 steps. The model proved to work well
for the analysis of learning from incidents in organisations and for the identification of difficulties
in this process, and shows how even minor problems impede all consequential steps, and
therefore strongly reduce the overall success of learning from incidents.
This dissertation summarises and discusses four sequential studies that were performed to
contribute to answering the research questions:
Study I (Drupsteen and Guldenmund, 2014) reviews the literature about learning from incidents.
The study categorised the identified articles according to their main topic, before comparing
them with the organisational learning theory of Argyris and Schön (1979). Study I found three
gaps in the literature: (a) there is limited research into the follow-up steps after incident
investigation; (b) the conditions for successful learning need further investigation; and (c) there is
only limited empirical research available on learning from incidents. This dissertation addresses
these research gaps.
Study II (Drupsteen, Groeneweg and Zwetsloot, 2013) considered the difficulties by using the
five-phase model of the learning from incidents process in a survey, and in three explorative case
studies. This study identified the main bottlenecks in the learning from incidents process, the
steps at which the learning process is impeded. The findings showed that bottlenecks particularly
occur in the planning and evaluation phase, and that as a result most of the information from
incident analysis is not effectively used for improvement in many organisations.
Study III (Drupsteen and Hasle, 2014) built on the insights of Study II. Study III aimed to identify
causes and conditions underlying the difficulties in the learning process. The findings are based
on seven focus group interviews in industrial and construction organisations and show five
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