| This exploratory case study describes the relationship between accident investigations and organizational learning. The research focused particular attention on the sensemaking and knowledge creation activities of accident investigation team members in the private sector. The Schwandt Organizational Learning Model (1997) was used as a theoretical framework for this research.; A group of 26 US chemical manufacturing sites volunteered to serve as the study's research sites. The confidentiality of their participation was protected by a written research agreement which assured that the identities of individuals, plants, and companies would not be revealed. In addition to literature reviews of both organizational learning and accident investigation, the primary sources of collected data came from semi-structured interviews, observations, and document reviews obtained during actual accident investigations from six of the participating chemical manufacturing plants which experienced a significant process accident. The accident investigation team activities were observed throughout the investigation process. Interviews were conducted at the manufacturing facilities in real time, immediately following the completion of the accident investigation activity. The interview participants were members of the accident investigation committees which were formed to investigate the industrial accident and to recommend corrective actions to prevent similar accidents from happening in the future. The typical committee membership included chemical operators, mechanics, production line supervisors, engineering and technical resources, and site safety professionals.; The results of this study revealed nineteen principal descriptors linking accident investigation activities with organizational learning. Five emergent themes were developed from the data analysis: the transfer of learning across plant and business, the importance of process structure in accident investigations, the investigation environment reflective of organizational culture, the accident investigation seen as a negative experience rather than as a learning opportunity, and accident investigation team training.; The study generated two major contributions related to the field of accident investigation and organizational learning. First, there was clear evidence of a relationship between accident investigations and organizational learning. Second, the descriptors and emergent themes uncovered in this research operationalized the Schwandt Organizational Learning Model (1997). In summary, this study provides a framework for future research utilizing the descriptors and emergent themes into other aspects of accident investigation and organizational learning. |
