Print Email Facebook Twitter Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn Title Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn Author Drupsteen, L. Hasle, P. Publication year 2014 Abstract If organizations would be able to learn more effectively from incidents that occurred in the past, future incidents and consequential injury or damage can be prevented. To improve learning from incidents, this study aimed to identify limiting factors, i.e. the causes of the failure to effectively learn. In seven organizations focus groups were held to discuss factors that according to employees contributed to the failure to learn. By use of a model of the learning from incidents process, the steps, where difficulties for learning arose, became visible, and the causes for these difficulties could be studied. Difficulties were identified in multiple steps of the learning process, but most difficulties became visible when planning actions, which is the phase that bridges the gap from incident investigation to actions for improvement. The main causes for learning difficulties, which were identified by the participants in this study, were tightly related to the learning process, but some indirect causes – or conditions – such as lack of ownership and limitations in expertise were also mentioned. The results illustrate that there are two types of causes for the failure to effectively learn: direct causes and indirect causes, here called conditions. By actively and systematically studying learning, more conditions might be identified and indicators for a successful learning process may be determined. Studying the learning process does, however, require a shift from learning from incidents to learning to learn. Subject Resilient OrganisationsSHB - Safe & Healthy BusinessELSS - Earth, Life and Social SciencesWork and EmploymentWorkplaceHealthy LivingOrganizationSafetyFailure to learnCausesCasesAccidentAccident preventionAccidentsLearning systemsIncident investigationLearning difficultiesLearning from incidentsLearning processLearning to learnSocieties and institutions To reference this document use: http://resolver.tudelft.nl/uuid:97482e1c-9d0c-4b33-a779-547b74f8b763 DOI https://doi.org/10.1016/j.aap.2014.07.027 TNO identifier 515132 Source Accident Analysis and Prevention, 72, 351-358 Document type article Files To receive the publication files, please send an e-mail request to TNO Library.