Organised Learning from Small-scale Incidents

Organised Learning from Small-scale Incidents

Koornneef, F.

Hale, A.R. (promotor)
De Mol, B.A.J.M. (promotor)

Technology, Policy and Management

2000-09-26

This thesis describes the search for and findings about methods and mechanisms that help organisations to learn cost-effectively from (small-scale) accidents and other undesired operational surprises. As it shows, organisational learning from such incidents is feasible, but must be organised. The Organisational Learning principles were used to help to synthesise and review the concept of a Systemic Incident Notification System (SINS). In addition, the Viable System Model provides a solid tool to scrutinise the SINS concept as well as lessons taken from earlier projects. The positioning of the incident monitoring & feedback function becomes much clearer in VSM perspective.

incident reporting
organisational learning
viable systems

http://resolver.tudelft.nl/uuid:fa37d3d9-d364-4c4c-9258-91935eae7246

Delft University Press

90-407-2092-4

Institutional Repository

doctoral thesis

(c) 2000 F. Koornneef