Organizational factors play a role in almost all accidents and are a critical part of understanding and preventing them. Two prominent sociological schools of thought have

Learning from experience, the cyclical interplay of thinking and doing, is increasingly important as organizations struggle to cope with rapidly changing environments and more complex and interdependent sets of knowledge. This paper confronts two central issues for organizational learning: (1) how is local learning (by individuals or small groups) integrated into collective learning by organizations? and (2) what are the differences between learning practices that focus on control, elimination of surprises, and single-loop incremental “fixing ” of problems with those that focus on deep or radical learning, double-loop challenging of assumptions, and discovery of new opportunities? We articulate these relationships through an analysis of learning practices in high-hazard organizations, specifically, problem investigation teams that examine the most serious and troubling events and trends in nuclear power plants and chemical plants. Our analysis suggests a four-stage model of organizational learning reflecting different approaches to control and learning. LEARNING FROM EXPERIENCE IN HIGH-HAZARD ORGANIZATIONS 1

The market-focused learning organization continues to attract attention in the marketing literature. Two central and interrelated aspects of collective learning are organizational culture and memory. The relationship between culture and performance has been demonstrated both theoretically and empirically. This study investigates the influence of culture and organizational memory development on perceptions of managers ’ decision-making context. Findings suggest that both organizational culture and memory influence marketing managers ’ perceptions of decision-making context. Specifically, managers in externally focused cultures tend to perceive a relatively higher proportion of strategic problems than managers in internally focused cultures, and managers in organic process cultures tend to perceive a relatively higher proportion of unstructured problems than managers in mechanistic cultures. The implications for managerial practice are discussed and avenues for future research outlined. Marketing managers are required to make decisions under difficult circumstances. There are few proscriptions or universal marketing laws to guide them, and a variety of

This paper has not undergone formal review or approval of the faculty of the ILR School. It is intended to make results of Center research available to others interested in preliminary form to encourage discussion and suggestions. Most (if not all) of the CAHRS Working Papers are available for reading at the Catherwood Library. For information on what’s available link to the Cornell Library Catalog:

Document complet disponible sur OLIS dans son format d’origine Complete document available on OLIS in its original format NEA/CSN/R(99)21/VOL1 ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT Pursuant to Article 1 of the Convention signed in Paris on 14th December 1960, and which came into force on 30th September 1961, the Organisation for Economic Co-operation and Development (OECD) shall promote policies designed: − to achieve the highest sustainable economic growth and employment and a rising standard of living in Member countries, while maintaining financial stability, and thus to contribute to the development of the world economy; − to contribute to sound economic expansion in Member as well as non-member countries in the process of economic development; and − to contribute to the expansion of world trade on a multilateral, non-discriminatory basis in accordance with

Document complet disponible sur OLIS dans son format d’origine Complete document available on OLIS in its original format NEA/CSNI/R(99)21/VOL2 ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT Pursuant to Article 1 of the Convention signed in Paris on 14th December 1960, and which came into force on 30th September 1961, the Organisation for Economic Co-operation and Development (OECD) shall promote policies designed: − to achieve the highest sustainable economic growth and employment and a rising standard of living in Member countries, while maintaining financial stability, and thus to contribute to the development of the world economy; − to contribute to sound economic expansion in Member as well as non-member countries in the process of economic development; and − to contribute to the expansion of world trade on a multilateral, non-discriminatory basis in accordance with

Document complet disponible sur OLIS dans son format d’origine Complete document available on OLIS in its original format

When Danish air traffic controller Peter Nielsen was murdered in 2004 by a Russian who lost his family at the Überlingen mid-air collision, this was only the last point of a big tragedy. 71 people lost their lives when a Boeing B-757 cargo aircraft and a Tupolew TU-154 commercial airliner collided in July 2002 over Germany, close to the Swiss border. Although several factors led to the disaster, it was also the inconsistent behaviour of the two pilots which contributed to the collision. One followed the instructions of the Traffic Alert and Collision Avoidance System (TCAS). The other followed the orders of the air controller. In this paper I argue that the redundancy systems which are constructed in order to increase safety in High Reliability Organisations (HRO) can conversely produce uncertainty. They can create situations in which decisions need to be made based on insufficient information. By reflecting on trust, culture and power I analyse why under these circumstances the commercial airliner might have been eventually steered according to the orders of the controller. Finally I apply aspects of Mathiassen and Sørensen‘s (2008) framework of Information Services to offer a theoretical explanation as to why the ultimate situation was impossible to resolve.

“Fiabilité et résilience comme dimensions de la performance organisationnelle” Guest Editors: Erik Hollnagel, Benoît Journé et Hervé Laroche.

people and cost billions of dollars in property damage. It was caused by a massive fire, which was not the result of an unpredictable “act of God ” but of an accumulation of errors and questionable decisions. Most of them were rooted in the organization, its structure, procedures, and culture. This paper analyzes the accident scenario using the risk analysis framework, determines which human decision and actions influenced the occurrence of the basic events, and then identifies the organizational roots of these decisions and actions. These organizational factors are generalizable to other industries and engineering systems. They include flaws in the design guidelines and design practices (e.g., tight physical couplings or insufficient redundancies), misguided priorities in the management of the tradeoff between productivity and safety, mistakes in the management of the personnel on board, and errors of judgment in the process by which financial pressures are applied on the production sector (i.e., the oil companies ’ definition of profit centers) resulting in deficiencies in inspection and maintenance operations. This analytical approach allows identification of risk management measures that go beyond the purely technical (e.g., add redundancies to a safety system) and also include improvements of management practices. KEY WORDS: Piper Alpha accident; offshore platforms; human error; organizational errors; postmortem analysis; probabilistic risk analysis.