Describes how organisations learn from past accidents and incidents and what changes they make to procedures , processes and equipment to enhance safety. Conference presentation.

1. Organisational Learning in Industrial
Companies – Experience from
Germany
Doytchin Doytchev & Ralph Hibberd
University of Paderborn &
Delft University of Technology

2. STRUCTURE OF THE PRESENTATION
1. Accident, Incident, Near Misses and the Work System
2. Organisational Learning
3. Goal and Research Questions
4. Analysis Approach
5. Results
6. Conclusions

3. 1. ACCIDENT AND INCIDENTAND THE
WORK SYSTEM
THE WORK SYSTEM
 Organisational artefacts - Authority structures, procedures, rules, etc.
 Physical artefacts – Machines, alarms, control systems, etc.
DEFINITIONS
ACCIDENT – Event that leads to injury, ill-health or damage to properties
INCIDENT - Event that hinders completion of a task and may cause injury or
other damage
NEAR MISSES - Undesirable events that can lead to damage to persons or
property, but did not due to deliberated or fortuitous change in
the operation conditions

4. 2. ORGANISATIONAL LEARNING
Definition (Koornneef, 2000)
A systematic process that:
 identifies and analyses operational surprises (a potentially hazardous
deviation from an expected state)
 Allow for the design, implementation and evaluation of corrective
measures.
 Review of past events including Accidents and Incidents (A&I).
 Enhancing organisational knowledge about its operation.
Requirements for effective Oranisational Learning (OL):
 A cyclic process of action and reflection by the organisation
 Knowledge creation by establishment of good information flow between
members and divisions

5. 2. ORGANISATIONAL LEARNING
OL system
people & means
make product
(work process)
Governing Vari-
ables (values,
norms, means)
surprise:
mismatch !
match
individual single-loop learning
Agencyorganisational single-loop learning
organisational double-loop learning
organisational unit
organisation
detect
inquire
adjust
notify
adjust
Figure 1. Organisational Learning process loops (Koornneef, 2000)

6. 3. GOAL AND RESEARCH QUESTIONS
STUDY GOAL: ESTABLISH THE PROPERTIES OF
MECHANISMS USED FOR OL IN GERMAN INDUSTRY
AND THE DEGREE TO WHICH THEY CAN PROMOTE
THE DESIGN OF SAFER WORK-SYSTEMS.
RESEARCH QUESTIONS:
 Which stakeholders participate in the A&I analysis?
 What are the types of change proposed to the work-system as a result of A&I
analysis?
 Who makes use of the information and knowledge that results from the A&I
analysis?

7. 4. ANALYSIS APPROACH
CRITERIA FOR SELECTING COMPANIES:
 A safety-critical domain (Chemical production, Power plants,
Pharmaceuticals)
 Accident distribution frequency – statistical data provided by the German
insurance organisation of the chemical and metal companies.
 Minimum number of employees in a company > 250.
RESEARCH APPROACH:
1. Design a questionnaire
2. Select industries to visit
3. Carry out a field study

8. 5. RESULTS
Type of Analysis
Respondents
N Percent-
age
Statistical 24 100%
Injuries sustained 11 45.5%
Time-events sequences 8 33.3%
Cost analysis 7 29.2%
Others 1 4.2%
Table 1. Analysis Applied to Accidents and
Incidents
0
2
4
6
8
10
Incident seriousness
Numberoforganisations
Not any
Not serios
Serious
Very serious
Extremely
serions
Fig. 2 Number of participating organisations who
reported one or more incidents during the
previous year

9. 5. RESULTS
Stakeholders responsible
Respondents
N Percent-
age
Safety engineer 17 89.5%
Plant manager 11 57.9%
Safety craftsman 8 42.1%
H&S committee 6 31.6%
H&S plant advisor 3 15.8%
H&S commissioner 1 5.3%
Table 3. People Responsible for Decision
Making on Information Collection and
Dissemination about Work-System Incidents
Table 2. Stakeholders Responsible for
Information Collection
Stakeholders Responsible
Respondents
N Percent-
age
Safety engineer or safety manager 11 73.3%
Plant manager 7 46.7%
Foreman 2 13.3%
Plant management 1 6.7%
Safety team 1 6.7%
Safety board 1 6.7%

10. 5. RESULTS
Information prepared
Respondents
N Percent-
age
Reports for different stakeholder
groups
14 77.8%
Distribution of information to other
parts of the company
11 61.1%
Feedback to designers 10 55.6%
Educational posters 8 44.4%
Discussion in relevant groups
related to safety
1 5.6%
Table 5. Use of Information with the Goal of
Improving Work-System Safety
Table 4. Information collected about the
Implementation of the Activities in the
Work-System
Information Collected
Respondents
N Percent-
age
Reports and safety audits 16 84.2%
Accidents and incidents
forms
13 68.4%
Observations 12 63.2%
Ergonomics reports 8 42.1%
Procedures for hazardous
control
1 5.3%

11. 5. RESULTS
Reasons
Respondents
N Percent-
age
Accidents or incidents 10 66.7%
Improvement recommendations 8 53.3%
Safety reports findings 8 53.3%
Others 8 53.3%
Near miss data 5 20.0%
Table 7. Reasons for Design changesTable 6. Type of Design Changes Made
14.3%
14.3%
2
2
Control system
21.4%3Workplace layout
28.6%4Communication channels, devices
and protocols
42.9%
35.7%
6Records
50.0%7Warnings, indicators, markers and
alarms
78.6%11Operating procedures and codes
78.6%11Rules and requirements
Percent-
age
N
Respondents
Information prepared
Checking and verification systems 5
Equipment design

12. 6. CONCLUSIONS
MECHANISMS FOR ORGANISATIONAL LEARNING DO EXIST, BUT
ARE NOT EFFECTIVE, DUE TO:
• Inefficient communication between various actors of the organisation.
• Presence of closed-loop of information flow regarding A&I analysis;
• Design changes are made rather to organisational artefacts than to
physical artefacts.
• Near misses have limited impact on changing operational practices
and artefacts.

13. THANK YOU FOR YOUR ATTENTION

14. QUESTIONS ?

15. OL system
people & means
make product
(work process)
Governing Vari-
ables (values,
norms, means)
surprise:
mismatch !
match
individual single-loop learning
Agencyorganisational single-loop learning
organisational double-loop learning
organisational unit
organisation
detect
inquire
adjust
notify
adjust