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This study explored the learning strategies used by different companies in response to occupational accidents.

Seventeen case studies were conducted with organisations from various industries via semi-structured interviews and analysis of documentation.

Providing context:

·        Organisational learning can be of any type that improves an organisation’s ability to perform its work better, in this case more safely while meeting other goals.

·        Learning can involve technical matters (equipment etc.), procedural (operating instructions), and personnel (competency).

·        Another perspective on learning divides it into technical and social. Technical stresses “that learning requires effective information processing, interpretation and its respective response/consequences” (p103). They cite Argyris and Schön’s seminal single and double loop learning concept. Social focuses on the role of social interaction processes in learning, e.g. “Approaches with this perspective either consider the learning as a social construction process, or as a political process, or as a cultural artifact” (p103).

·        The technical/social lens suggests 4 types of accident learning strategies: diffusion, discussion, training and change. Diffusion is the dissemination of accident info; discussion is the next step and includes an exchange of views on the accident’s info; training refers to the use of accident data to improve worker understanding; change implies the change of modifying something after the fact, work design, equipment, routines.

·        An advantage of this study’s protocol is that it explored post-accident learning strategies from across the learning cycle phases – from initial accident data collection, to analysis, conclusions, distribution, training/awareness and interventions

[** And yes, incident data is still just one focused stream of data and shouldn’t overwhelm or distract the organisational routines of learning and improving from everyday work. However, these findings are likely also indicative of the maturity of an organisations to prospectively learn from everyday work.]

Results

Some key findings were that:

·        All analysed organisations had established procedures to report accidents and to collect accident data, but there were “organizations that still do not maximize their means of learning from work accidents” (p102)

·        Organisations with “good safety practices tend to follow the complete learning cycle” (p102)

·        Further, “only a few companies have, in fact, a full learning cycle that could allow them to optimize or achieve a better learning outcome” (p112)

·        Four different learning maturity levels were delineated from these organisations – from level 1 with minimal learning practices, to level 4 requiring a high learning capacity

·        As expected, having OHSAS certification represented a mixed-bag. For one, it was, of course, no magical solution for improving learning; i.e. “OHSAS certification is not related to a company’s level of learning” (p110)

·        However, organisations with an integrated Quality, Environment and & OHS system were more likely to have more mature learning practices across the lifecycle [** noting we have no idea on the direction of the relationship, e.g. did integration assist in learning practices, or were mature learning organisations more likely to seek integration?]

Discussing the findings, first they note that accreditation is “not always the (magical) answer/solution for a better safety system” and simply having “formal standards and rules is not actually enough, nor is it synonymous with having a system that works as it should” (p110).

Despite this, as noted above, having an integrated system was associated with more mature learning practices.

Fig 1 below highlights the topological configuration of learning patterns at each of the four levels of learning maturity – 1 being the lowest and 4 the highest.

At level 1 organisations are doing the minimum, being collecting accident data but having no formal procedures about who collects the info, no formal methods of analysis, and how to provide or circulate the findings. Level 4 undertakes deep analysis, improvements and circulation.

The authors argue that “only at levels 4 and 3 (Fig. 1) can one accept or state that organizations are really learning from their accidents” (p107).

The authors then graphically plot the 17 organisations on the same maturity dimensions (not shown here).

Although there was a distribution of industries across the maturity levels, construction was over-represented with 5 companies towards the lower tiers of learning (as said in the paper “complying only with the legal requirements”); whereas two construction companies were in the higher tiers. Because of the limited sample size, little can probably be concluded about industry.

Organisations at the higher tiers had broader definitions of what is an occupational accident, stricter than legal definitions. That is, these higher performing organisations tended to record and analyse “all” accidents and incidents. They also tended to disseminate info across all hierarchical levels and better involve the workforce in the active collection and reporting of safety.

They found that some organisations that appeared to have mature learning practices at the outset were later found to not maximise learning through the lifecycle. E.g. weaknesses were found: not implementing changes after investigations, no revision to system/process, lack of internal discussion on contributing factors, learning processes that centralised entirely around a few select people with higher responsibilities, lacking involvement across all hierarchical levels, and lacking an effective communication strategy to disseminate findings.

A limitation of this study is that it evaluated only formalised learning practices, not informal practices that take place in groups, departments etc. They note that social learning practices may occur effectively in places without good formal practices, and vice versa.

Another limitation is that the inputs of data came only from OHS management, not other facets of work and performance.

Authors: Silva, S. A., Carvalho, H., Oliveira, M. J., Fialho, T., Soares, C. G., & Jacinto, C. (2017). Safety science, 99, 102-114.

Study link: https://doi.org/10.1016/j.ssci.2016.12.016

LinkedIn post: https://www.linkedin.com/pulse/organizational-practices-learning-work-accidents-cycle-ben-hutchinson