Organizational effects of experience from accidents. Learning in the aftermath of the Tretten and Åsta train accidents

This article explores possible signs on learning in organizations following two major railway accidents in Norway, the Tretten accident in 1975 and the Åsta accident in 2000. These are the most serious railway accidents to have occurred in the past decades and both involved collisions on a single track system. The two events have been analyzed and compared in order to investigate possible learning effects and possible differences in learning given the 25-year span between them. The study is based on the analysis of selected documents related to the accidents in general and the narrative components in the documentation related to learning in particular.

[1]  D. Schoen,et al.  The Reflective Practitioner: How Professionals Think in Action , 1985 .

[2]  Andrew W Evans.  Rail safety and rail privatisation in Japan. , 2010, Accident; analysis and prevention.

[3]  John A. Stoop.  Accident investigations: trends, paradoxes and opportunities , 2002 .

[4]  Nancy G. Leveson,et al.  A new accident model for engineering safer systems , 2004 .

[5]  R. Charon.  Narrative Medicine: Honoring the Stories of Illness , 2006 .

[6]  Andrew W Evans,et al.  Fatal train accidents on Europe's railways: 1980-2009. , 2014, Accident; analysis and prevention.

[7]  Robert E. Jupe,et al.  ‘ A Deficient Performance ? ’ : The Regulation of the Train Operating Companies in Britain ’ s Privatised Railway System , 2004 .

[8]  Chris W. Johnson,et al.  PII: S0951-8320(99)00066-6 , 1999 .

[9]  Trevor Kletz.  Accident Investigation—Missed Opportunities , 2002 .

[10]  Zdravko Kaltnekar,et al.  Organization and Information Systems , 1995 .

[11]  Andrew Hopkins,et al.  Failure to Learn: The BP Texas City Refinery Disaster , 2008 .

[12]  Anne Silla,et al.  The development of railway safety in Finland. , 2012, Accident; analysis and prevention.

[13]  Donald A. Schön,et al.  The Reflective Practitioner: How Professionals Think in Action. , 1987 .

[14]  Andrew W Evans,et al.  Rail safety and rail privatisation in Britain. , 2007, Accident; analysis and prevention.

[15]  Andrew W. Evans,et al.  The economics of railway safety , 2013 .

[16]  Pascal Béguin.  Risky Work Environments: Reappraising Human Work Within Fallible Systems , 2009 .

[17]  Julian Wolfreys,et al.  Readings: Acts of Close Reading in Literary Theory , 2000 .

[18]  B. Flyvbjerg.  Five Misunderstandings About Case-Study Research , 2006, 1304.1186.

[19]  Gunhild Halvorsrud.  The Åsta Train Crash, its Precursors and Consequences, and its Investigation , 2002, SSS.

[20]  Ove Njå,et al.  INVESTIGATION OF INCIDENTS IN SYSTEMS DESIGNED OR DEVELOPED ON THE BASIS OF RISK ANALYSES , 2011 .

[21]  Sverre Roed-Larsen,et al.  Public safety investigations - A new evolutionary step in safety enhancement? , 2009, Reliab. Eng. Syst. Saf..

[22]  Ove Njå,et al.  A model for learning in emergency response work , 2013 .

[23]  Chris W. Johnson.  A case study in the integration of accident reports and constructivedesign documents , 2001, Reliab. Eng. Syst. Saf..

[24]  H. C. Blakstad,et al.  Reverse invention: An inductive bottom-up strategy for safety rule development: A case study of safety rule modifications in the Norwegian railway system , 2010 .

[25]  E. Jakobsson.  Accident Investigations: a comparative perspective on societal safety in Norway and Sweden, 1970–2010 , 2011 .

[26]  D E Maurino,et al.  Beyond Aviation Human Factors: Safety in High Technology Systems , 1995 .

[27]  G. S. Braut O. Njå,et al.  Learning from accidents (incidents) – Theoretical perspectives on investigation reports as educational tools , 2009 .