Learning Failures As the Ultimate Root Causes of Accidents

  • Nicolas Dechy
  • Yves Dien
  • Eric Marsden
  • Jean-Marie Rousseau


Drawing on their ample experience in high-risk industries, the authors show that a number of major accidents have been preceded by warnings raised by people who attempted, unsuccessfully, to alert actors who had the ability to prevent a danger they perceived. The authors demonstrate that, very often, the dissenting opinions and whistleblowers were not heard due to cultures in which bad news was not welcome, criticism was frowned upon, or where a “shoot the messenger” attitude prevailed. Instead, performance pressures push systems in the direction of failure and lead organizations to reduce their safety margins. As a result, a “new normal” is established, and no significant problems are noticed until it is too late.


  1. Amalberti, R., C. Vincent, Y. Auroy, and G. De Saint-Maurice. 2006. Violations and migrations in health care: A framework for understanding and management. Journal of Quality and Safety in Health Care 15 (1): i66–i71.CrossRefGoogle Scholar
  2. Blatter, C., N. Dechy, and S. Garandel (2016). Vers un retour d’expérience prenant en compte les facteurs organisationnels et humains. édité par l’IMdR.
  3. Bourrier, M. 2011. The legacy of the high-reliability organization project. Journal of Contingencies and Crisis Management 19 (1): 9–13.CrossRefGoogle Scholar
  4. Carroll, J., and B. Fahlbruch. 2011. Honoring B. Wilpert, “The gift of failure: New approaches to analyzing and learning from events and near-misses”. Safety Science 49 (1): 1–106.CrossRefGoogle Scholar
  5. Carroll, J.S., J.W. Rudolph, and S. Hatakenaka. 2003. Learning from organizational experience. In Blackwell handbook of organizational learning and knowledge management, ed. M. Easterby-Smith and M.A. Lyles, 575–600. Malden: Blackwell.Google Scholar
  6. Columbia Accident Investigation Board. 2003. Report. Vol. 1. Washington, DC: National Aeronautics and Space Administration.
  7. Cullen, W. D. [Lord] 2000. The Ladbroke Grove rail inquiry. Part 1 and part 2 reports. Norwich: HSE Books, Her Majesty’s Stationery Office. [Report Part 2: 2001].Google Scholar
  8. Cyert, R.M., and J.G. March. 1963. A behavioural theory of the firm. Cambridge, MA: Blackwell.Google Scholar
  9. Dechy, N., Y. Dien, and M. Llory. 2009. Les échecs organisationnels du retour d’expérience. INERIS report N°DRA-08-95321-15660A, 23/12/2008.
  10. ———. 2010. For a culture of accidents dedicated to industrial safety. Congrès λμ17 de l’IMdR. La Rochelle, October 5–7.Google Scholar
  11. Dechy, N., J.-M. Rousseau, and F. Jeffroy. 2011a. Learning lessons from accidents with a human and organisational factors perspective: Deficiencies and failures of operating experience feedback systems. EUROSAFE 2011 conference, Paris.Google Scholar
  12. Dechy, N., J.-M. Rousseau, and M. Llory. 2011b. Are organizational audits of safety that different from organizational investigation of accidents? ESREL conference, Troyes, France, September 18–22.Google Scholar
  13. Dechy, N., Y. Dien, E. Funnemark, S. Roed-Larsen, J. Stoop, T. Valvisto, and A.-L. Vetere Arellano, on behalf of ESReDA Accident Investigation Working Group. 2012. Results and lessons learned from the ESReDA’s accident investigation working group. Safety Science 50 (6): 1380–1391.CrossRefGoogle Scholar
  14. Dechy, N., J.-M. Rousseau, Y. Dien, M. Llory, and R. Montmayeul. 2016. Learning lessons from TMI to Fukushima and other industrial accidents: Keys for assessing safety management practice. Proceedings of the IAEA international conference on human and organizational aspects of assuring nuclear safety – Exploring 30 years of safety culture. Proceedings of the IAEA conference on the 30 years of safety culture. Vienna, Austria, February 22–26.Google Scholar
  15. Dekker, S. 2008. Just culture: Balancing safety and accountability. Aldershot: Ashgate.Google Scholar
  16. Department Of Energy. 2005. Action plan on lessons learned from the Columbia Space Shuttle accident and Davis-Besse reactor pressure-vessel head corrosion event.
  17. Detert, J.R., and A.C. Edmondson. 2011. Implicit voice theories: Taken-for-granted rules of self-censorship at work. Academy of Management Journal 54 (3): 461–488. Scholar
  18. Dien, Y., and M. Llory. 2005. Veille technologique et scientifique, accidents, incidents et crises – Les “marqueurs” de facteurs organisationnels pathogènes: Cas de la NASA à partir des données de l’accident de la navette Columbia – rapport EDF R&D HT-52/05/020/A.Google Scholar
  19. Dien, Y., M. Llory, and R. Montmayeul. 2004. Organisational accidents investigation methodology and lessons learned. Journal of Hazardous Materials 111: 147–153.CrossRefGoogle Scholar
  20. Dien, Y., N. Dechy, and E. Guillaume. 2012. Accident investigation: From searching direct causes to finding in-depth causes. Problem of analysis or/and of analyst? Safety Science 50 (6): 1398–1407.CrossRefGoogle Scholar
  21. Drupsteen, L., and F.W. Guldenmund. 2014. What is learning? A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management 22 (2): 81–96.CrossRefGoogle Scholar
  22. Eddy, P., E. Potter, and B. Page. 1976. Destination disaster. London: Hart-Davis, MacGibbon.Google Scholar
  23. Edmondson, A.C. 1999. Psychological safety and learning behavior in work teams. Administrative Science Quarterly 44 (2): 350–383. Scholar
  24. ESReDA. 2009. Guidelines for safety investigation of accidents.
  25. ———. 2015. Barriers to learning from incidents and accidents. ESReDA technical report, coordinated by E. Marsden.
  26. Ferjencik, M. 2011. An integrated approach to the analysis of incident causes. Safety Science 49: 886–905.CrossRefGoogle Scholar
  27. Frei, R., J. Kingston, F. Koornneef, and P. Schallier. 2003. Investigation tools in context. Proceedings of the JRC/ESReDA 24th seminar on “Safety investigation of accidents.” Petten: The Netherlands, May 12–13.
  28. Goffman, E. 1959. The presentation of self in everyday life. New York: Doubleday.Google Scholar
  29. Hagen, J. 2013. Confronting mistakes: Lessons from the aviation industry when dealing with errors. Houndmills/Basingstoke/Hampshire: Palgrave Macmillan.Google Scholar
  30. Hayes, J. 2015. Taking responsibility for public safety: How engineers seek to minimise disaster incubation in design of hazardous facilities. Safety Science 77: 48–56.CrossRefGoogle Scholar
  31. Hollnagel, E., D.D. Woods, and N.C. Leveson, eds. 2006. Resilience engineering: Concepts and precepts. Aldershot: Ashgate.Google Scholar
  32. Hopkins, A. 2010. Failure to learn: The BP Texas City refinery disaster. Sydney: CCH Australia.Google Scholar
  33. Kingston, J., R. Frei, F. Koornneef, and P. Schallier. 2007. Defining operational readiness to investigate (DORI). White paper 1.Google Scholar
  34. Kingston J., Y. Dien, and N. Dechy. 2011. Safer access to space and hard lessons from soft sciences: Organisational failures and challenges learned from space and technological disasters. Proceedings of the space access international conference, Paris, France, September 21–23.Google Scholar
  35. Koornneef, F. 2000. Organised learning from small-scale incidents. PhD thesis, Delft, The Netherlands, Delft University Press.Google Scholar
  36. Langåker, L. 2007. An inquiry into the front roads and back alleys of organisational learning. Proceedings of the organization learning, knowledge and capabilities conference. London, Ontario.
  37. Leveson, N. 1995. Safeware, system safety and computers – A guide to preventing accidents and losses caused by technology. Boston: Addison-Wesley.Google Scholar
  38. Leveson, N., and C. Turner. 1993. An investigation of the Therac-25 accidents, 0018-9162/93/0700-0018 – IEEE. Computer 26 (7.) (July): 18–41.CrossRefGoogle Scholar
  39. Llory, M. 1996. Accidents industriels: le coût du silence, Opérateurs privés de parole et cadres introuvables. Paris: Éditions L’Harmattan.Google Scholar
  40. ———. 1999. L’accident de la centrale nucléaire de Three Mile Island. Paris: Éditions L’Harmattan.Google Scholar
  41. Llory, M., and Y. Dien. 2006. Les systèmes sociotechniques à risques: Une nécessaire distinction entre fiabilité et sécurité. Performances n°30, n°31, n°32.Google Scholar
  42. Llory, M., and R. Montmayeul. 2010. L’accident et l’organisation. Editions Préventique.Google Scholar
  43. Marsden, E. 2014. Ed. Groupe de travail REX FonCSI coordonné par E. Marsden, Quelques bonnes questions à se poser sur son dispositif de retour d’expérience, Les cahiers de sécurité industrielle, n° 2014–01.
  44. McIntyre, G. 2000. Patterns in safety thinking – A literature guide to air transportation safety. Aldershot: Ashgate.Google Scholar
  45. Merritt, C.W. 2007. Testimony of Carolyn W. Merritt, U.S. CSB, Before the US House of Representatives. Committee on energy and commerce, subcommittee on investigations and oversight, May 16.Google Scholar
  46. Myers, L. 2002. Management and human root causes, Davis-Besse Nuclear Power Station. FENOC, August 15.Google Scholar
  47. National Diet of Japan. 2012. The official report of the Fukushima nuclear accident independent investigation commission. Executive summary. Tokyo: National Diet of Japan.Google Scholar
  48. Nuclear Regulatory Commission. 2002. Issues “Lessons learned” task force report on agency’s handling of Davis-Besse reactor vessel head damage. NRC News, US Nuclear Regulatory Commission.Google Scholar
  49. Ramanujam R., and J. Carroll. 2013. Learning from failure. In Grote and Carroll (2013), Safety management in context – Cross-industry learning for theory and praxis. June 19–21, 2013. White Book edited by Swiss Re Centre for Global Dialogue.
  50. Rasmussen, J. 1997. Risk management in a dynamic society: A modelling problem. Safety Science 27 (2/3): 183–213.CrossRefGoogle Scholar
  51. Rasmussen, J., and I. Svedung. 2000. Proactive risk management in a dynamic society. Technical report. Karlstad: Swedish Rescue Services Agency.
  52. Reason, J. 1997. Managing the risks of organizational accidents. Aldershot: Ashgate.Google Scholar
  53. Rousseau, J.-M. 2008. Safety management in a competitiveness context. EUROSAFE forum proceedings, Paris, France, November 3–4.Google Scholar
  54. Rousseau, J.-M., and A. Largier. 2008. Conduire un diagnostic organisationnel par la recherche de facteurs pathogènes, Techniques de l’Ingénieur AG 1576.Google Scholar
  55. Rousseau J.-M. et al. 2014. Faire du REX aujourd’hui: pourquoi? comment? – Repères pour un retour d’expérience événementiel source d’apprentissages, rapport IRSN PSN-SRDS/2014–00019.
  56. Santayana, G. 1905. The life of reason. Ithaca: Cornell University Library.Google Scholar
  57. Sklet, S. 2004. Comparison of some selected methods for accident investigation. Journal of Hazardous Materials 111 (1–3): 29–37.CrossRefGoogle Scholar
  58. Snook, S.A. 2000. Friendly fire, the accidental shootdown of US Black Hawks over Northern Iraq. Princeton: Princeton University Press.CrossRefGoogle Scholar
  59. Starbuck, W.H., and P. Baumard. 2005. Learning from failures: Why it may not happen. Long Range Planning 38: 281–298.CrossRefGoogle Scholar
  60. Turner, B., and N. Pidgeon. 1997. Man-made disasters. Second ed. Oxford: Butterworth Heinemann. [First edition: Turner, B. (1978). Wykeham Publications].Google Scholar
  61. US Chemical Safety and Hazard Investigation Board. 2007. Investigation report, refinery explosion and fire, BP – Texas City. Texas, March 23, 2005. Report no 2005-04-I-TX.
  62. Vaughan, D. 1996. The challenger launch decision. Risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.Google Scholar

Copyright information

© The Author(s) 2018

Authors and Affiliations

  • Nicolas Dechy
    • 1
  • Yves Dien
    • 2
  • Eric Marsden
    • 3
  • Jean-Marie Rousseau
    • 1
  1. 1.Fontenay-aux-RosesFrance
  2. 2.ParisFrance
  3. 3.ToulouseFrance

Personalised recommendations