Learning from experience in high-hazard organizations

Learning from experience, the cyclical interplay of-thinking and doing, is increasingly important as organizations struggle to cope with rapidly changing environments and more complex and interdependent sets of knowledge. This paper confronts two central issues for organizational learning: (1) how is local learning (by individuals or small groups) integrated into collective learning by organizations? and (2) what are the differences between learning practices that focus on control, elimination of surprises, and single-loop incremental "fixing" of problems with those that focus on deep or radical learning, double-loop challenging of assumptions, and discovery of new opportunities? We articulate these relationships through an analysis of learning practices in high-hazard organizations, specifically, problem investigation teams that examine the most serious and troubling events and trends in nuclear power plants and chemical plants. Our analysis suggests a four-stage model of organizational learning reflecting different approaches to control and learning.