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Do Organisations Learn?

I want to end this chapter with a brief discussion of organisational learning. Organisations create risk through their routine operations, and they implement controls to minimise or mitigate those risks. Controls include rules and procedures, practices and surveillance (audit and reporting systems being forms of surveillance). As we have seen, all of these controls are fallible. Normal operations are subject to routine non-conformities which occasionally become anomalies. In the worst case, an anomaly becomes a public catastrophe: failure is now visible. There will always be a tension between control and chaos and an effective learning organisation actively seeks evidence of potential failure. All organisations need to be flexible and adaptive and to be able to respond to changes in their operating environment. Resilience flows from effective oversight of the operation and meaningful engagement with practitioners to generate learning. Hollnagel (2009) offers the following four cornerstones of a resilient organisation:

  • 1. Respond to events
  • 2. Monitor ongoing developments
  • 3. Anticipate future threats and opportunities
  • 4. Learn from past failures and successes

From these, we can see that monitoring ongoing developments will be impaired if reporting systems are inadequate.

Learning can be challenging for two reasons. The first is that success is the expected outcome of work, and it can be hard to identify why success occurred other than the crew just did their job as planned. The second is that organisations respond badly to adverse events. The short-lived low-cost carrier ‘Go’ had two B-737s takeoffs from London Stansted Airport in the space of 2 weeks with the nose gear pin still in place (personal communication). As a result, the aircraft had to land in order to have the pin removed. It was made known to the crew that the next person to take-off without removing the gear pin would lose their job. A few weeks later, a crew was about to depart. It was a wet day and visibility was poor. The captain looked out to see what he thought was the ground engineer holding the nose gear pin with its florescent flag. Thinking they were safe to go, the crew departed. Unfortunately, it was not the warning flag they could see but the high visibility markings on the sleeve of the wet weather jacket of the engineer. The mood of the company management was transmitted to the workforce but the way it shaped behaviour was not quite as intended.

An effective learning organisation displays four characteristics (Easterby-Smith & Araujo, 1999):

  • 1. It actively generates information.
  • 2. It integrates that information into the organisational context.
  • 3. The organisation makes a collective attempt to interpret the new data through some form of interaction.
  • 4. Individuals and groups are encouraged to take action based on a shared understanding of the problems raised.

These characteristics overlap HollnageTs cornerstones of resilience but, of interest, is the suggestion that learning arises from collaborative action at an organisational level with individuals empowered to act based on new knowledge generated through this shared understanding. Organisational learning requires effort, but it seems that, often, the action is an afterthought. Hollnagel proposes that a resilient organisation is anticipatory, and we saw in Chapter 1 that an effective training system should deliver competence designed to cope with potential risks to the operation rather than rehearse past events.

How Level 3 Works

The work of Level 3 is to configure assets and develop processes that generate a return on investment (or, in the case of not-for-profit operations such as air ambulance and police, provide a capability for a defined term within the budget). The decisions made at Level 3 and, thus, its defining characteristics, are to do with protecting and accruing capital. The task of the crew is to fulfil the obligation the company has with the customer: they deliver on the contractual promise made by the company to the client. Those operational controls that are put in place (checklists and procedures) fall under the auspices of regulatory oversight. The company must negotiate with the agents of the regulator as part of the obligations that flow from holding an air operators certificate. This chapter has explored other forms of control: those which are implicitly exercised through the discretionary behaviour of the company, facilitated by the uneven power balance between the employees and their employers. Rational management interventions, however, result in unintended responses, and control mechanisms trigger acts of organisational citizenship and resistance.

Feedback is another component of my system that, supposedly, validates the conduct of operations. Feedback to Level 3 is implicit, in the main: production targets are met, aircraft depart and arrive. Other forms of formal feedback include captains’ voyage reports, flight data capture and reports from third parties (complaints or reports of violations). Again, the value of feedback is dependent upon organisations having the capacity and mechanisms for receiving, processing and aggregating information into useful knowledge. The examples we have seen here suggest that feedback, in the shape of attendance rates, policy buy-in and reporting systems, represents signals suggestive of dysfunctional ity.

Safety is undoubtedly influenced by Level 3 processes to the extent that they support or impede work at the lower levels. Throughout this book, we have seen examples of job designs, resourcing and scheduling (or rostering) that have had an influence on the way crews have been able to do their job. At one extreme, the design of the job has been an impediment. At the other, crews have lacked the physical and mental resource to cope with demands. In a systems context, Level 3 decisions reduce the buffering available either directly through structural elements such as policies and procedures, equipment, maintenance and job design or indirectly through influencing crew capability. A fundamental emergent property of Level 3, I would suggest, is morale.


This chapter has attempted to map out a framework that explores the relationship between legitimate management action and potential worker responses. Once again, we see that the activity is manifested in decisions that shape policies which then feed through to action in the workplace. Policies influence decisions made in the workplace. I have long argued that ‘management’ is a capability that can be characterised in terms of quantity and quality. Managers need sufficient capacity to cope with the demands of their role but also the skills to effect policies that will achieve the intended, rather than the unintended, goals. Where management is ineffective, the system migrates from one of resilience to one where small disturbances will be catastrophic. Ineffective management facilitates safety drift through an inability or an unwillingness to anticipate outcomes and take appropriate action.


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