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Organised Learning from Small-scale Incidents

By F. Koornneef
December 2000
Delft University Press
ISBN: 90-407-2092-4
247 pages, illustrated
$84.00 paper original

This Ph.D. thesis describes the search for & findings about methods & mechanisms that help organizations to learn cost-effectively from (small-scale) accidents & other undesired operational surprises. As it turns out, organizational learning from such incidents is feasible, but must be organized. The Organizational Learning principles were used to help to synthesize & review the concept of a Systemic Incident Notification System (SINS). In addition, the Viable System Model provides a solid tool to scrutinize the SINS concept as well as lessons learned from earlier projects. The positioning of the incident monitoring & feedback function becomes much clearer in VSM perspective.