No theory forbids me to say "Ah!" or "Ugh!", but it forbids me the bogus theorization of my "Ah!" and "Ugh!" - the value judgments. - Theodor Julius Geiger (1960)

Are We Learning From Accidents?

Nippin Anand’s new book is about accident investigations, learning from failures, and creating a culture that embraces fallibility and humanizes risks. I have read it and wanted to share my ideas about it.

The book starts with forewords by Steven Shorrock and Rob Long and an introduction titled "Failure was Never an Option," which sets the stage for discussing the importance of understanding and learning from accidents. For this, Nippin writes, we need an ethic, a philosophy, and a method of enquiry.

Chapter 1 discusses using a multidisciplinary perspective in accident investigations. Our quest for learning never ends and leads to a temporal, unstable truth. This made me think about the desire in modern life to desperately make the world available and knowable, while true vitality and real experiences come from encounters with the unavailable. I recommend reading Hartmut Rosa’s book ‘The Uncontrollability of the World’ (Rosa, 2020).

Chapter 2 examines the ritual of investigating accidents, the components of this ritual, and its dys-/functions. Nippin writes about the existential need to find a root cause. This made me think of Norbert Elias’ writing about the need to explain changes of figurations by means of changes of figurations, movements by means of movements, not by means of an “Ur-sache” (root cause), “a primal cause that, so to speak, forms a beginning and does not move” (Elias, 2014).

Chapter 3 focuses on the storytelling aspect and how narratives of heroes and anti-heroes are formed. I agree with Nippin that fallibility is denied on a large scale. One example I remember is the institutional confidence that rendered contingency planning unnecessary for nuclear accidents; this was rooted in a belief that nuclear risks are objectively calculable and entirely preventable, unlike other threats (Downer, 2013). This chapter fits really well with my role as a sociologist and myth hunter. Also, I agree with the statement that we need competing narratives. Pierre Bourdieu's practice theory (Bourdieu, 1990) has taught me about 'illusio', the immersive engagement and belief in the stakes and dynamics of a particular social practice or game. This 'illusio' contains the collective commitment and acceptance of the rules, values, and objectives inherent to that practice, which participants internalize and act upon as if they were inherently meaningful and valuable (Bourdieu, 1990). An external observer, without this engagement, does not perceive the same urgency or significance. Participants are focused on the imminent future and the ongoing flow of actions, unlike the static, detached view of an analyst who sees events without the same immediate pressures. It's a valid point with implications for investigations, as purely objective models fail to capture the internal logic and meaningfulness of practices as experienced by those engaged in them. It's important to take this into account. That goes for our own organizations too; I bet that even your safety department has more than one monolithic orientation, as multiple games are played at the same time, be it the current games of traditional safety management and HOP.

Chapter 4 highlights the role of interpersonal relationships in learning from accidents. A person is more than his behavior or omissions. This, of course, fits well with my ideas as a sociologist. Instead of simply focusing on our own choices or solely on those of others, we should reflect on the relationships and power dynamics at play, and how these factors may be influencing decision-making. As health and safety professionals, we can benefit from being physically present and sharing emotional experiences with others. This can help us to understand the emotions and motivations of the people we work with, and to build stronger relationships with colleagues and stakeholders.

Chapter 5 explores cognitive and physical aspects of learning. Engaging with the embodied mind/whole person. Readers might have some trouble taking this in. The embodiment view of the mind suggests that the body plays a crucial role in shaping the mind, especially when it comes to emotions. Our thoughts and concepts arise from our physical experiences and interactions with the world. These experiences create simulators that combine sensory, motor, and internal bodily information to form our understanding. Language helps us categorize and understand these emotional experiences, leading to varied emotional responses depending on the context. Emotions are seen as complex events that integrate various sensory and cognitive inputs into a unified experience. For a thorough explanation, I recommend reading Lisa Feldman Barrett’s book ‘How Emotions are Made’ (Feldman Barrett, 2017).

Even after reading Nippin’s description in this chapter, I’m still a bit skeptical about the one brain three minds metaphor (1B3M). Maybe Rasmussen’s SRK-model is more enlightening to me. 1B3M made me think of the ‘triune brain’, as introduced by neuroscientist Paul MacLean in the 1960s. It posited that the human brain evolved in three stages: the reptilian brain that is responsible for survival instincts; the limbic brain which handles emotions, and the neocortex, which manages higher-order thinking and reasoning. But the brain does not have distinct layers that evolved sequentially. Brain evolution involved reorganization, where existing structures adapted and changed in size and function. Emotions, rationality, and survival instincts are not confined to separate parts of the brain but are integrated across its entire structure. All regions of the brain work together to regulate emotions and behaviors (Feldman Barrett, 2020).

Chapter 6 is about the need for open questioning and skepticism in the learning process. The stories we gather always remain incomplete. Often, we want closure too quickly. As human beings, we predict what happens in the world. Even before the senses pick up stimuli, the brain is already predicting what the input from those senses will be. Then the senses are used to check the predictions for their usefulness and survival value. The brain does not like prediction errors and either (1) quickly updates its model of the world or (2) intervenes in the world to adjust it to fit the expectations.

Chapter 7 discusses how criticism and ridicule can hinder learning.

Chapter 8 looks at how emotions impact the learning process. As accident investigators, we can help people realize their emotions and express their feelings.

Chapter 9 discusses how unconscious factors contribute to learning. I struggled with this chapter since it’s heavily influenced by Jungian analytical psychology of which I'm quite critical. Jung devalued rational thought and overemphasized myth. Jung's psychoanalytic methods led patients away from practical problem-solving and deeper into their fantasies and visions, thereby exacerbating their mental health issues. Jung's theories blend philosophical and mystical traditions with early psychiatric models, which makes them appealing yet scientifically dubious. One of the problems I have is with the ‘collective unconscious’. Individual psychological processes are modified through social interaction. Social environments have an impact on individual psychology; individuals' behaviors and mental processes can change when influenced by a group. But these changes remain rooted in individual psychology; they don’t require the postulation of a collective unconscious. (Full disclosure: I'm a sociologist, and I share Georg Simmel's point of view regarding social psychology (Simmel, 2009)).

Chapter 10 advocates for accepting mistakes (fallibility) as part of the learning process.

Chapter 11 consists of a detailed examination of the Costa Concordia disaster.

Chapter 12 analyzes how routine practices like the Costa Concordia’s sail-past can contribute to accidents. Together with later chapters, especially chapter 14, this description of what happened at Costa Concordia and the aftermath of the disaster was very enlightening to me.

Chapter 13 investigates the reasons behind silence and lack of communication in organizations. The buzzwords ‘psychological safety’ are used skeptically. The problem is cultural and relational; it’s in the expert-novice culture. It reminded me of Georg Simmel’s classic book ‘Sociology’. Knowledge of others and trust play crucial roles in social interactions. Our perception of others is influenced by both objective facts and subjective interpretations. Human knowledge is inherently limited, and we often present a curated version of ourselves to others. Secrets contribute to individualization and differentiation within social structures. Secrecy operates within companies too, and trust and the ability to keep silent are of importance. Centralization and anonymity of leadership intensify obedience. Members of secret societies often lose their distinct personalities, becoming mere numbers or roles within the group. This depersonalization reduces individual responsibility. It would be nice to know if these issues played a role at the Costa Concordia.

Chapter 14 discusses the emergency response plan of Costa Concordia (rescue-as-imagined) and the real emergency response (rescue-as-done). It adequately describes how ‘fantasy planning’ has real consequences: stories of culpability and crime.

Chapter 15 critiques the concept of a no-blame culture in accident investigations. It describes how the rapid increase in the demand for cruise services was a struggle for both the operators and the regulators. It lists the functions of scapegoating (in this case Captain Francesco Schettino) and urges us to embrace fallibility and the fallible person with our whole being.

Chapter 16 offers practical advice and the ICue method for learning from accidents. I found that the diagrams in this chapter were hard to read because of small print.

A concluding section nicely synthesizes the insights from the book.

The Appendix provides a detailed case study or report on a specific accident.

- Anand, N. (2024), Are We Learning From Accidents? A Quandary, A Question and a Way Forward, Novellus.

- Bourdieu, P. (1990), The Logic of Practice, translated by Richard Nice, Stanford University Press.

- Downer, J. (2013), Disowning Fukushima: Managing the credibility of nuclear reliability assessment in the wake of disaster, in: Regulation & Governance, Volume 8, Issue 3, September 2014, Pages 287-309.
- Elias, N. (2014 [1970]), Was ist Soziologie? (What is Sociology?), 12. Auflage, BeltzJuventa Grundfragen der Soziologie.
- Feldman Barrett, L. (2017), How Emotions Are Made - The Secret Life of the Brain, London: Macmillan.
- Feldman Barrett, L. (2020), Seven and a Half Lessons About the Brain, Mariner Books.
- Rosa, H. (2020), The Uncontrollability of the World, Polity.

- Simmel, G. (2009), Sociology - Inquiries into the Construction of Social Forms, translated/edited by Blasi, A.J., Jacobs, A.K., Kanjirathinkal, M., Leiden/Boston: Brill.