Incident Reviews in High-Hazard Industries: Sense Making and Learning Under Ambiguity and Accountability

Abstract

Learning from practical experience is of greater importance in more complex work environments. In high-hazard industries, complexity, tight coupling, and invisibility make safe operation and learning from experience particularly difficult. There is growing recognition that further improvement is needed and that it will require more than incremental improvement and exchange of "best practices." This arti cle describes how organization members make sense of practical expe rience in one high-hazard industry—nuclear power—and how their sense-making affects their decisions and actions. The author discusses four factors that can limit the effectiveness of the interpretive process: root cause seduction, sharp-end focus, solution-driven search, and account acceptability. He then examines the impact that myopic inter pretations can have on operating performance by placing incident reviews within the organizational learning process, and he closes with suggestions for a cross-disciplinary research agenda.