Learning from Postmortems in Hazardous Contexts

This resource first appeared in issue #44 on 02 Oct 2020 and has tags Technical Leadership: Systems: Incident Handling

Incident Reviews in High-Hazard Industries: Sense Making and Learning Under Ambiguity and Accountability - Thai Wood, Resilience Roundup
Incident Reviews in High-Hazard Industries: Sense Making and Learning Under Ambiguity and Accountability - John S. Carroll, Industrial & Environmental Crisis Quarterly (1995)

This is is a recent blog post about a less recent paper, reviewing how incident reviews work in high-hazard industries like nuclear power.

Whether the environment is life-critical or just inconvenient like a research cluster going down, a common incident review failure mechanism is to focus on the fix to the presenting problem. Wood and Carroll argue that instead the focus should be learning and adapting and trying to avoid or improve responses to entire classes of problems. Wood identifies failures of incident reviews as:

• Root cause seduction
• Sharp end focus
• Solution driven searches
• Account adaptability