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Organised lessons

A two-year project to boost expertise on organisational learning has been launched by the PSA as part of its follow-up of major accidents and serious incidents.


This article was originally published in
Safety - Status and Signals 2012-2013

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Major international accidents have contributed to greater understanding, knowledge and awareness of complexity and risk conditions in the Norwegian petroleum industry.

These incidents include the Texas City explosion in 2005, the Montara blowout off Australia in 2009 and the Macondo blowout in the Gulf of Mexico the following year.

The Alexander L Kielland and Piper Alpha disasters during the 1980s also provided dearly bought experience and lessons for Norway’s oil and gas sector.

Called Culture and System for Learning, the new project will provide the basis for utilising knowledge of organisational learning from a safety perspective both at the PSA and in the industry, and look into factors in organisations which may promote or hamper such learning.

In addition to experienced specialists and managers from all PSA disciplines, the project will draw on expertise at the University of Stavanger, research institutes and other relevant players.

The work also embraces technical discussions with the authority’s counterpart in the UK, the Health and Safety Executive.

“This will be a kind of ‘hub activity’, where seek to pull together a number of current developments and supervisory activities,” explains project manager Jorunn Tharaldsen.

“Our relatively small organisation in the PSA also gives us a unique experience base multidisciplinary programmes of this kind.”

It means that the specialists concerned heavily involved in other technical projects, supervisory work, investigations and development of regulations, she notes.

“Covering analyses of our own RNNP data, audit results and literature reviews, this project will help us to discover how both we and the industry can learn.

“Involving qualified people who’re able to challenge us along the way will be crucial to the success of the work.” A question like “how are learning processes in the companies influenced by the PSA’s words and deeds, and do these necessarily have the desired effect” is a reminder that good intentions are by no means enough, Tharaldsen observes.
“Knowledge and experience from our investigations demonstrate how important is to be aware of the perspectives for such inquiries as a basis for learning.

“You often find what you look for. a general challenge that investigations pay little attention to operational parameters and organisational factors which have contributed negatively to an incident.”

“We’ve kicked off the project by seeking to place organisational learning in a system perspective and to develop a coherent model,” says Sigve Knudsen, the PSA’s discipline manager for occupational health and safety.

“We’re interested in our own and industry’s ability to learn from history, in detailed reporting on major accidents, in the investigation of serious incidents, and in fully documented supervisory activities.”

History is an important source of learning, Knudsen notes:

“But it’s not enough to acquire hindsight if organisations are to learn. “We must also have an eye to future challenges by studying trends and development aspects, and by being prepared for the possibility that the inconceivable could happen.” This is why the PSA pursues continuous leading-edge and multidisciplinary development, parameter-setting and supervisory activities as the basis for meeting present and future challenges.

“We must not only keep an eye on the rear mirror, but also have the ability to look into our crystal ball,” Knudsen emphasises.

Such an approach to learning additionally requires a coherent overview of and in- sight into the risk picture, and a robust and competent organisation with the ability and willingness to manage risk.

“This means we must constantly update our established knowledge and regulations, and define them more precisely,” says Knudsen.

“That could be in such areas as barrier management, management and major accident risk, and other important contributors to the risk picture.

“Our own requirements for continuous learning and development are at the heart of all these activities. Quantitative and qualitative analyses from the RNNP process make an important contribution to learning in every phase.”

He points out that knowledge and an overall view are not enough to ensure genuine organisational learning. Experience, expertise, cooperation, and understanding of human interaction and organisation also play an important role.

Researchers have so far sought critical success factors for organisational learning, he says. But new knowledge points to important aspects which can inhibit or promote such lessons.

“Key concepts are vulnerability and robustness, levels of control and conflict, power and powerlessness. All these are elements in an organisational culture and its setting.

“Learning processes in the petroleum industry are complex, not least because they take place at the interface between a number of players.”