| dc.description.abstract | This study has focused on incident reporting and organizational learning in a petroleum company, with one of its installations as a case object. The goal of the thesis was to map possible challenges in reporting and learning practices after incidents in the Company and at the case object. The study s problem to address was: What influences the incident reporting practices, and how are reports used for organizational learning? The problem has been addressed through two research questions:
What factors inhibits and promotes reporting?
How can organizational learning from incident reporting be improved?
Incident reporting provide important information to manage safety in organizations. The theoretical framework includes inhibiting and promoting factors for incident reporting. The inhibiting factors relies to a large extent on the degree of trust in organizations and a central factor is that lack of trust can lead to under-reporting due to a fear of personal consequences. Promoting factors relates to the reporting system and is based on three principles by Sidney Dekker: a voluntary, non-punitive and protected system. In addition, a clear distinction between acceptable and unacceptable behaviour, are considered to prevent the inhibiting factors.
Semi-structured interviews have been the main method of collecting information in this study. 16 informants were interviewed. In addition, observations and secondary data material from the Company, have been used. The informants are from the sharp end only. This gives this empirical study a limitation in analysing the topic in only one perspective. Due to limitations in time and scope, there may exist other perspectives on the topic that this study does not present.
The interviews with the informants revealed both promoting and inhibiting factors for incident reporting. The promoting factors were: a common understanding of the purpose of incident reporting and that incident reporting cards are easy to use. The inhibiting factors mentioned were: lack of trust, fear of consequences, uncertainty about where the line is drawn, insufficient feedback on reports, a comprehensive Safety Information System (SIS) database with excess information, and the possibility to be anonymous when reporting.
The inhibiting factors for incident reporting have been assessed to have negative effect on organizational learning. Under-reporting is considered to limit the information input to SIS, which complicates information handling in the system and may affect the information output. Insufficient information output has negative effect on establishing measures, organizational learning, and experience transfer.
There are different meeting formats at the case object today. Morning meetings, department meetings and HSE meetings considered as learning arenas for experience transfer. The informants express that they wish more focus on organizational learning and learning arenas open for discussions. Such measures can have positive effects on sharing of knowledge and experience transfer.
The study concludes by giving the following recommendations for improving reporting and learning practices in the company:
Ensure user involvement when updating procedures and establishing measures
Improve the management visibility and commitment on every level
Implement more user-friendly digital tools for making reporting easier and accessible
Utilize common learning arenas to discuss, increase knowledge and build trust | en |
