Learning From Organizational Incidents: Resilience Engineering for High-Risk Process Environments

Research output: Contribution to journalArticle


For years, safety improvements have been made by evaluating incident reports and analyzing errors and violations. Current developments in safety science, however, challenge the idea that safety can meaning-fully be be seen as the absence of errors or other negatives. Instead, the question becomes whether a company is aware of positive ways in which people, at all level of the organisation, contribute to the management and containment of the risks it actually faces. The question, too, is whether the organization has the adaptive capacity necessary to respond to the changing nature of risk as operations shift and evolve. This article presents the results of a resilience engineering safety audit conducted on a chemical company site. An interdisciplinary team of seven researchers carried out 4 days of field studies and interviews in several plants on this site. This company enjoyed an almost incident-free recent history but turned out to be ill-equiped to handle future risks and many well-known daily problems. Safety was often borrowed from to meet acute production goals. Organizational learning from incidents was fragmented into small organization or production units without a company-wide learning. We conclude that improving safety performance hinges on an organization's dynamic capacity to reflect on and modify its models of risk as operations and insight into them evolve, for example, as they are embodied in safety procedures and policies. (C) 2008 American Institute of Chemical Engineers Process Saf Prog 28: 90-95, 2009


  • Stefanie Huber
  • Ivette van Wijgerden
  • Arjan de Witt
  • Sidney Dekker
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Other Engineering and Technologies not elsewhere specified


  • incident reporting, chemical industry, anticipation, resilience engineering, hazards, accidents
Original languageEnglish
Pages (from-to)90-95
JournalProcess Safety Progress
Issue number1
Publication statusPublished - 2009
Publication categoryResearch