OECD Workshop: Learning from crises and fostering the continuous improvement of risk governance and management - Prof. Ove Njå

University of Stavanger uis.no

Perspectives on learning from recent crises and research Ove Njå Professor, risk management and societal safety

1

25-Sep-2014

Disaster cases?

Accident/Year Number of fatalities

Risk management focus in the investigation reports

Petroleum sector Texas City Refinery, 2005 15 Yes Gas leak Oseberg C, 2008 0 No Railway sector Åsta, Røros-line, 2000 19 Yes Alnabru/Sjursøya, 2010 3 Yes

Njå & Braut 2012

Case 1 Texas City Refinery Disaster (U.S. Chemical Safety and Hazard Investigation Board (CSB))

The disaster scrutiny: Observation – assessment – investigation – evaluation?

Right Wrong

Smart

Dumb

Theoretic

A-theoretic

Disaster risk?

5

Fast: Instant Slow: Creeping

Fast: Abrupt Fast-burning crisis Cathartic crisis

Slow: Gradual Long-shadow crisis Slow-burning crisis

Speed of development Sp

eed

of t

erm

inat

ion

(’tHart & Boin, 2001)

Challenges for reflection and discussion

’tHart & Boin’s typology is retrospective – risk is futuristic There is no ontology of risk (Solberg & Njå, 2012) Risk is about epistemological claims – we are all affected There is a philosophical battle, not only about risk, but several

major concepts in safety science. For example how to deal with uncertainty?

Ethical considerations related to a stronger societal introduction to «black swans»?

Learning is also a contested concept

6

A few words on learning

Not consistent terminology, neither on national nor international level

Learning has to be identified on a broader basis than observation of changes

(also confirmation of knowledge and gaining comprehension of existing practice)

For this purpose using criteria on learning that can be identified as common for several theoretical approaches: Developmental (e.g. Piaget) Social constructivist (e.g. Vygotsky) Participative (e.g. Schön, Lave & Wenger)

Learning – (ACCILEARN)

“processes related to establishing new knowledge aiming to implement changes to, gaining deeper comprehension of and/or confirming the basis for current apprehensions and practices”

(Braut & Njå, 2009)

Learning from investigations

”Independent variables” ”Dependent variables”

”Collective learning”? ”Storytelling”?

The investigation process Collection of information Context Interpretation Th

e re

port

The story: ”Plot” ”Players”

The investigation results

The risk picture – risk image

The reception history - non-instrumental - instrumental

Who are the actors expected to learn?

The exposed (victims, injured, next of kin)

The directly involved (personnel in; bluelights, volunteers,

emergency management, government, media coverage)

The indirectly involved (other bluelight organisations, emergency

management, government, politicians etc)

«Opportunity consultancies» (R&D sector, universities,

consultancies, media)

Public

So what? Our findings

As an educational tool the investigated investigation report may be divided in two parts: First part – highly empirical, descriptive, Second part – normative, without strong textual explicit or implicit links to the first

part

The first part can be regarded as a possible educational text – suitable for real learning

The second part is a set of normative advice, possibly related to the first part, but possibly also based on other inputs/presumptions – may be claimed as social ritual

Learning from this disaster event?

Model for learning from crises

(Sommer, Njå & Braut)

Context

Commitment Content

PERSON

Change, Confirmation

and/or Comprehension

Reflection

Decision making

and Response

Open to learning

Åsta-accident

Braut, Solberg & Njå 2014

Investigations do not give organisations new knowledge but encourage measure implementation

Incident themselves triggers activity in affected organizations

Involved parties do not wait for investigators to determine responsibility or reveal hidden causes

Incident causes are understood by relevant professionals immediately, without the investigation

Model for learning from crises and research

(Sommer, Njå & Braut)

Context

Commitment Content

PERSON

Change, Confirmation

and/or Comprehension

Reflection

Decision making

and Response

Open to learning