Elsevier

Safety Science

Volume 79, November 2015, Pages 80-87
Safety Science

Learning from incidents: Practices at a Scandinavian refinery

https://doi.org/10.1016/j.ssci.2015.05.001Get rights and content

Highlights

  • We examine practices for learning from incidents at a Scandinavian refinery.

  • Practices to learn from incidents were far from uniform among refinery employees.

  • Learning from incidents occurred through structured activities and daily worktasks.

  • Leaders and engineers emphasized learning about management systems and procedures.

  • Operators found learning with regard to individual skills important after incidents.

Abstract

This paper reports on a study of practices used to learn from incidents with the aim of improving safety performance in a Scandinavian refinery. Data for the study was collected during five months of fieldwork at the refinery and interviews with 70 refinery employees. In this paper, we examine how managers, engineers and operators at the refinery participated in activities aimed at learning from incidents. Incident learning did not just happen through formal incident management processes, but also through daily work practices. Hence, workplace learning may be an interesting lens through which to examine employee practices to learn from incidents. We found that employees executed learning-related tasks in different ways from formal presentation of reports and risk reducing measures to informal meetings and discussion raising the reflexivity of employees. We conclude this paper with recommendations for learning practices in large-scale industrial environments.

Introduction

Few would deny that learning is important in organizations that work with high-risk technologies in dynamic and volatile environments. Much research is devoted to understanding how this process can be expressed and measured, how the “right lessons”1 can be learned and how companies can facilitate more efficient and effective learning (see e.g. Drupsteen et al., 2013, Hovden et al., 2011, Jacobsson et al., 2011). Organizational and safety research has identified a variety of factors that either inhibit or facilitate learning from incidents (see e.g. Pidgeon and O’Leary, 2000, Schilling and Kluge, 2009, Smith and Elliott, 2007, Størseth and Tinmannsvik, 2012).

But there is still much to learn about the actual practice of incident learning. We do not really know how learning “happens” in the day-to-day work in high-risk industries. What we need are empirical studies of the practices by which organizational members seek to learn from incidents and try to incorporate lessons in their working routines (Lindberg et al., 2010).

One industrial sector in which these processes may be studied is the oil and gas industry. Learning in this sector is both critically important and very hard. Recent disasters (think of the Deepwater Horizon disaster in 2010) underline the importance of learning (Skogdalen, 2011). At the same time, the BP Texas City, Tesoro Anacortes, Longford and Buncefield accidents have shown that it may not be easy to learn the right lessons.2 The petroleum processing and refining industry is a highly competitive globalized industry with large, and, in Europe, often aging production facilities (Wood et al., 2013). The industry has to balance the need to reduce costs with the necessity to improve safety performance.

In this paper, we present findings from an exploratory study of a Scandinavian refinery. We wanted to study a refinery where there was a systemic emphasis on learning from incidents. We chose our particular refinery in a country where the regulation regime and national supervisory body prioritize learning from incidents and accidents at petroleum-related facilities.

We selected this particular refinery because it was the largest refinery in the host country and because it had been the site of several serious incidents during the 2000s.3 In the context of the European refinery industry, it is a medium-sized refinery. The refinery consists of a natural gas liquids fractionation plant, a crude oil terminal and crude storage facilities, a combined heat and power plant and a refinery with a refining capacity of 12 million tons per year. The refinery used a safety barrier approach and risk-based tools as part of its safety management (Vinnem, 2007).

This organization was a real “learning lab” given the many incidents it had to handle. The company that owned and operated the refinery granted access to the site and all relevant documentation. The refinery organization had been criticized by the supervisory authority for not doing enough to learn from incidents following an audit in 2010. However, the selected refinery was working to improve learning from incidents, and was willing to allow the lead author of this paper access to its operations and employees.

The research questions were straightforward: What do practices aimed at learning from incidents consist of, how are they carried out and what are their results? In this article we describe how employees understood and experienced activities to learn from incidents as part of their working lives. Our research is based on analyses of extensive fieldwork and interviews with 70 employees at the refinery. We start by discussing theoretical perspectives on incident learning. We then present the findings of our fieldwork. After discussing our findings, we conclude with an overview of implications for practice and theory.

Section snippets

Theoretical perspectives on learning from incidents

Organizations that work with complex, high-risk technologies in volatile environments cannot afford to wait for a crisis or disaster to happen and then start learning. They must exploit every opportunity to learn. Every incident or near-miss represents such an opportunity.

Organizations that do this all the time and continue to perform successfully are described as being High Reliability Organizations (HROs). In recent years, we have seen the rise of these HROs in the safety literature (see e.g.

Studying learning practices

Studies of the literature on incident learning describe a need for empirical studies (Le Coze, 2013, Lindberg et al., 2010, Drupsteen and Guldenmund, 2014). Our study is based on extensive fieldwork, making use of observations and interviews. It provides insight into the variety of processes that make up efforts to learn in a single organization. It shows – despite an organization’s attempt to control and direct learning efforts – how practices, and the way employees experience them, can vary.

Learning practices at the refinery

We found that practices aimed at learning from incidents took place both in a structured, formal way (using an incident management system), as well as in other, less structured and more informal ways. Below we first describe who participated in activities aimed at learning. We then describe the nature of these activities. Finally, we consider how respondents perceived the results of their participation.

Discussion

Research on incident learning in the safety and organizational sciences tends to examine instrumental processes that do or do not lead to learning (see e.g. Crossan et al., 1999, Kjellén, 2000, Kolb, 1984, Ramanujam and Goodman, 2011, Størseth and Tinmannsvik, 2012). These process theories of learning make universal claims regarding the suitability of certain types of learning process and lesson types.

We understand learning from incidents as processes of knowledge development, which may

Conclusion: Lessons for practice and research

We were fortunate to gain access to a large refinery, which allowed us to study practices of learning in the wake of incidents. We used a practice-oriented approach, focusing both on formal and informal learning processes. Our findings yield some intriguing insights that may be beneficial to others who study incident learning, in academia or practice.

Learning from incidents is not exclusively governed by a safety or incident management system. It can also be realized by individuals and groups

Role of the funding source

Statoil, the owner of the refinery where the research for this article was carried out, funds the PhD project that this article is a part of. The company has had no involvement in determining the nature or extent of data collection, interpretation and analysis of collected data, in determining the content of the article or the decision to submit the article for publication.

Acknowledgements

We wish to thank Statoil for funding the research that is presented in this article and for allowing access to their refining facility. We are grateful to all employees who allowed us to shadow them during their workday and who were interviewed as part of this project.

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