Organised Learning from Small-scale Incidents

Doctoral thesis (2000)

Authors

Contributors

A.R. Hale (promotor)
B.A.J.M. De Mol (promotor)
Faculty
Technology, Policy and Management (TPM) (TU Delft)
Copyright: © 2000 F. Koornneef
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Published Date

26-09-2000

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Faculty

Technology, Policy and Management

Abstract

This thesis describes the search for and findings about methods and mechanisms that help organisations to learn cost-effectively from (small-scale) accidents and other undesired operational surprises. As it shows, organisational learning from such incidents is feasible, but must be organised. The Organisational Learning principles were used to help to synthesise and review the concept of a Systemic Incident Notification System (SINS). In addition, the Viable System Model provides a solid tool to scrutinise the SINS concept as well as lessons taken from earlier projects. The positioning of the incident monitoring & feedback function becomes much clearer in VSM perspective.