oecd workshop: learning from crises and fostering the continuous improvement of risk governance and...
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Presentation by Prof. Ove Njå, Stavanger University, Norway. The workshop on “Learning from crises and fostering the continuous improvement of risk governance and management”, jointly organised with the governments of the Netherlands, Norway and Sweden, was held in Oslo, Norway on 17-18 September 2014. More information is available at www.oecd.org/gov/risk/high-level-risk-forum-oslo-workshop-2014.htmTRANSCRIPT
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University of Stavanger uis.no
Perspectives on learning from recent crises and research Ove Njå Professor, risk management and societal safety
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25-Sep-2014
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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
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Case 1 Texas City Refinery Disaster (U.S. Chemical Safety and Hazard Investigation Board (CSB))
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The disaster scrutiny: Observation – assessment – investigation – evaluation?
Right Wrong
Smart
Dumb
Theoretic
A-theoretic
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Disaster risk?
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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)
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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
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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)
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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)
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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
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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
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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
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Learning from this disaster event?
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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
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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
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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