ABSTRACT
A critical component of a high resilience in organizations is continuous learning from events, 'near miss' incidents, and accidents. This chapter explores some of the barriers that can limit learning even by generally very high quality organizations. It presents a case study of learning from incidents. Analysis of the case reveals a discounting or distancing process whereby reviewers focus on differences, real and imagined, between the place, people, organization and circumstances where an incident happens and their own context. A chemical fire occurred during maintenance on a piece of process machinery in the clean room of a large, high technology product manufacturing plant. The fire was detected and automatically extinguished by safety systems that shut off the flow of reactants to the machine. The chemical fire case reveals the pressures to discount or distance ourselves from incidents and accidents. In this organization, effective by almost all standards, managers, safety officers, and workers took a narrow view of the precursor event.
