Learning from incidents: From normal accidents to high reliability

David L. Cooke, Thomas R. Rohleder

Research output: Contribution to journalArticle

117 Citations (Scopus)

Abstract

Many disasters have occurred because organizations have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past. Normal accident theory suggests that disasters are the unwanted, but inevitable output of complex socio-technical systems, while high-reliability theory sees disasters as preventable by certain characteristics or response systems of the organization. We develop an organizational response system called incident learning in which normal precursor incidents are used in a learning process to combat complacency and avoid disasters. We build a model of a safety and incident learning system and explore its dynamics. We use the model to motivate managers to implement incident learning systems as a way of moving safety performance from normal accidents to high reliability. The simulation model behavior provides useful insights for managers concerned with the design and operation of incident learning systems.

Original languageEnglish (US)
Pages (from-to)213-239
Number of pages27
JournalSystem Dynamics Review
Volume22
Issue number3
DOIs
StatePublished - Sep 2006
Externally publishedYes

Fingerprint

Disasters
incident
Accidents
accident
Learning systems
disaster
learning
Managers
Reliability theory
manager
simulation model
Incidents
learning process
organization
Disaster
performance

ASJC Scopus subject areas

  • Management of Technology and Innovation
  • Strategy and Management
  • Social Sciences (miscellaneous)

Cite this

Learning from incidents : From normal accidents to high reliability. / Cooke, David L.; Rohleder, Thomas R.

In: System Dynamics Review, Vol. 22, No. 3, 09.2006, p. 213-239.

Research output: Contribution to journalArticle

Cooke, David L. ; Rohleder, Thomas R. / Learning from incidents : From normal accidents to high reliability. In: System Dynamics Review. 2006 ; Vol. 22, No. 3. pp. 213-239.
@article{917af1832bda431dada3091d41f12d45,
title = "Learning from incidents: From normal accidents to high reliability",
abstract = "Many disasters have occurred because organizations have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past. Normal accident theory suggests that disasters are the unwanted, but inevitable output of complex socio-technical systems, while high-reliability theory sees disasters as preventable by certain characteristics or response systems of the organization. We develop an organizational response system called incident learning in which normal precursor incidents are used in a learning process to combat complacency and avoid disasters. We build a model of a safety and incident learning system and explore its dynamics. We use the model to motivate managers to implement incident learning systems as a way of moving safety performance from normal accidents to high reliability. The simulation model behavior provides useful insights for managers concerned with the design and operation of incident learning systems.",
author = "Cooke, {David L.} and Rohleder, {Thomas R.}",
year = "2006",
month = "9",
doi = "10.1002/sdr.338",
language = "English (US)",
volume = "22",
pages = "213--239",
journal = "System Dynamics Review",
issn = "0883-7066",
publisher = "John Wiley and Sons Ltd",
number = "3",

}

TY - JOUR

T1 - Learning from incidents

T2 - From normal accidents to high reliability

AU - Cooke, David L.

AU - Rohleder, Thomas R.

PY - 2006/9

Y1 - 2006/9

N2 - Many disasters have occurred because organizations have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past. Normal accident theory suggests that disasters are the unwanted, but inevitable output of complex socio-technical systems, while high-reliability theory sees disasters as preventable by certain characteristics or response systems of the organization. We develop an organizational response system called incident learning in which normal precursor incidents are used in a learning process to combat complacency and avoid disasters. We build a model of a safety and incident learning system and explore its dynamics. We use the model to motivate managers to implement incident learning systems as a way of moving safety performance from normal accidents to high reliability. The simulation model behavior provides useful insights for managers concerned with the design and operation of incident learning systems.

AB - Many disasters have occurred because organizations have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past. Normal accident theory suggests that disasters are the unwanted, but inevitable output of complex socio-technical systems, while high-reliability theory sees disasters as preventable by certain characteristics or response systems of the organization. We develop an organizational response system called incident learning in which normal precursor incidents are used in a learning process to combat complacency and avoid disasters. We build a model of a safety and incident learning system and explore its dynamics. We use the model to motivate managers to implement incident learning systems as a way of moving safety performance from normal accidents to high reliability. The simulation model behavior provides useful insights for managers concerned with the design and operation of incident learning systems.

UR - http://www.scopus.com/inward/record.url?scp=33845327850&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=33845327850&partnerID=8YFLogxK

U2 - 10.1002/sdr.338

DO - 10.1002/sdr.338

M3 - Article

AN - SCOPUS:33845327850

VL - 22

SP - 213

EP - 239

JO - System Dynamics Review

JF - System Dynamics Review

SN - 0883-7066

IS - 3

ER -