Learning From Incidents And Implementing Action: Exploring Expectations And Contradictions In The Energy Sector

Murphy, Vicky Louise (2020). Learning From Incidents And Implementing Action: Exploring Expectations And Contradictions In The Energy Sector. PhD thesis The Open University.

DOI: https://doi.org/10.21954/ou.ro.00010f9d

Abstract

Learning from incidents (LFI) is an organisational learning process whereby accidents or near-misses are used to stimulate learning in order to prevent similar events in the future. Prior research has demonstrated that an important step in LFI is the distribution of incident summaries to enable individuals, teams, networks and organisations to learn. These summaries should in theory support vicarious learning for those not directly involved in the original event. This thesis investigates the following major gaps in LFI literature: the role of networks in LFI, what practitioners perceive to be successful learning in the context of LFI, beneficial practices in LFI, and current barriers that prevent successful LFI.

These gaps were investigated through a mixed method multi-case study design across three large energy organisations. The research explored the responses of over 160 participants to two surveys, and 45 semi-structured interviews.

The first key finding, related to network use in LFI, was that, within each organisation, the structure of both formal and informal networks was dependent on contextual factors, such as geographical dispersal of workers. Within each of the organisations, employees use their networks in similar ways: to exchange information and to understand the connection between an incident and a worker’s own practice.

The second key finding addressed the gap on what practitioners perceive to be successful learning through identifying a taxonomy of 24 learning objectives associated with LFI. The taxonomy included observable outcomes, such as changes in best practice, and included objectives necessary to foster an effective learning process, such as open communication.

A finding related to beneficial practices in LFI was the identification of a unique approach to LFI within each of the three organisations: one organisation used technology to support communication related to LFI; another held safety events that considered multiple incidents related to a single process; the third created opportunities for workers from different teams to meet and discuss incidents through a variety of inter-departmental meetings.

The final key finding of this research was the deduction of four contradictions observed across the three organisations that created barriers to learning: a lack of differentiation between safety and learning; perceived irrelevance of some incident alerts; inconsistent pedagogical support for learning; and an inability to differentiate between incidents that had occurred due to the probabilistic nature of events, or a lack of learning.

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