Fallible decisions in management: learning from errors

Blanco, Juan Calvo; Lewko, John H.; Gillingham, David

doi:10.1108/09653569610112871

Cited by 16 publications

(13 citation statements)

References 7 publications

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“…A traditional approach to learning from incidents is that when an analysis is performed with care and lessons are formulated, this will lead to the prevention of incidents [6,12,13,14]. However, learning from incidents should not only focus on preventing recurrence, but also on making an organisation inherently safer and on improving the learning from incidents process itself.…”

Section: Introductionmentioning

confidence: 99%

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

Drupsteen¹,

Groeneweg

Zwetsloot

2013

International Journal of Occupational Safety and Ergonomics

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Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploraorganisational learning incident survey learning potential case studies

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Section: Introductionmentioning

confidence: 99%

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

Drupsteen¹,

Groeneweg

Zwetsloot

2013

International Journal of Occupational Safety and Ergonomics

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“…'You have to prepare but you can't be prescriptive', as another senior manager put it, 'because each incident is different'. These views, widely echoed, chime with observations in the literature, which warn, in turn, that disasters cut across the local jurisdictions within which plans are framed and that plans edit out uncertainties, depicting partial or distorted data as if it were precise (Smithson, 1990;Blanco, Lewko, and Gillingham, 1996;Smallman and Weir, 1999). Perry (2004, p. 65) criticises 'lengthy plans that attempt to anticipate every possible event and prescribe correctives'.…”

Section: Planning and Preparationmentioning

confidence: 99%

Organisational challenges in the United Kingdom's post‐disaster ‘crisis support’ work

Davis

2016

Disasters

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Local authorities in the United Kingdom are required to 'lead' multi-agency humanitarian responses to major disasters. Concerns mounted in the late twentieth century that responses to people bereaved in the immediate aftermath of such events at best failed to meet their needs and at worst compounded their distress. Subsequent reviews and reforms reframed some victim needs as 'rights' and established legal, administrative, and practice frameworks to improve matters. Local authority 'crisis support', provided in partnership with other actors, lies at the heart of the UK's contemporary emergency response to the bereaved. Drawing on primary research on the development and the deployment of crisis support in a local authority, and while acknowledging both incident- and context-related difficulties, this paper considers the significance of challenges with their origins in organisational factors. Recent developments within and between responders may exacerbate them. This paper argues, therefore, that further research into such developments is necessary.

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“…Another weakness, as noted by Shrivastava et al (1988), is that despite inquiries being conducted and recommendations made, the farreaching and radical organi sational, technical and regulatory changes needed to eliminate identified underlying causes have occurred at a very slow pace. Thus, governments and organisations need to enhance their ability to learn from past incidents in order to reduce the frequency and severity of future errors (Blanco, Lewko and Gillingham, 1996). The learning phase has received the least attention from scholars, practitioners, management and the media because organisational learning efforts are costly in terms of time and effort and are the least dramatic and visible in the short term (Argyris and Schon, 1978;KoracBoisvert and Kouzmin, 1995).…”

Section: Statusmentioning

confidence: 99%

Inquiries into Malaysia's socio‐technical disasters: recommendations and lessons learnt

et al. 2009

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Most democratic countries hold inquiries into disasters. One of their key functions is to establish the cause of an event and to learn lessons in order to prevent a recurrence. In addition, they offer an opportunity for communal catharsis, permitting the public to vent anger, distress and frustration and to exert pressure for policy changes. Malaysia has experienced six landmark socio-technical disasters since 1968, which resulted in the proposal or amendment of various safety/emergency acts and regulations. The authors used a grounded theory approach utilising a constant comparative method to analyse the recommendations made by the inquiries into these events. Data indicate that social and technical recommendations comprise 85 and 15 per cent, respectively, of the total recommendations made by the inquiry committees. This paper offers suggestions for improving the management of inquiry tribunals, as they will remain a valuable source of information for society and corporations to learn from past incidents.

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Fallible decisions in management: learning from errors

Cited by 16 publications

References 7 publications

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

Organisational challenges in the United Kingdom's post‐disaster ‘crisis support’ work

Inquiries into Malaysia's socio‐technical disasters: recommendations and lessons learnt

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