Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn

If organizations would be able to learn more effectively from incidents that occurred in the past, futureincidents and consequential injury or damage can be prevented. To improve learning from incidents,this study aimed to identify limiting factors, i.e. the causes of the failure to effectively learn. In sevenorganizations focus groups were held to discuss factors that according to employees contributed to thefailure to learn. By use of a model of the learning from incidents process, the steps, where difficulties forlearning arose, became visible, and the causes for these difficulties could be studied.Difficulties were identified in multiple steps of the learning process, but most difficulties became visiblewhen planning actions, which is the phase that bridges the gap from incident investigation to actions forimprovement. The main causes for learning difficulties, which were identified by the participants in thisstudy, were tightly related to the learning process, but some indirect causes – or conditions – such aslack of ownership and limitations in expertise were also mentioned.The results illustrate that there are two types of causes for the failure to effectively learn: direct causesand indirect causes, here called conditions. By actively and systematically studying learning, more condi-tions might be identified and indicators for a successful learning process may be determined. Studyingthe learning process does, however, require a shift from learning from incidents to learning to learn