1.13 LEARNING OPPORTUNITIES LOST
As is demonstrated in Chapters 2 and 3, boards of inquiry and coroners are tasked through their terms of reference to find causes, to identify why existing controls failed, and to determine who was responsible. In essence, and most unfortunately, apportioning blame has a high priority. Whilst it is necessary for legal and disciplinary reasons to determine if individual neglect contributed to the tragic outcomes, such investigations can produce unfortunate by-products as far as learning is concerned.
Understandably those touched by an accident, or subsequent investigations, may be emotionally stressed or even alienated. When this happens, learning opportunities are lost.
In subsequent chapters, it is argued that unless we take deliberate action to minimise loss of learning opportunities, we will neither learn from past events, accidents, incidents or catastrophes, nor go on to use that learning to inform behaviour, and inform future decisions and strategies. Massive gains may be achieved by facilitating the understanding and learning among managers and decision makers. Equally, there may be substantial barriers to achieving valuable learning outcomes.
Of course, lessons can be found in the minutia of reports of boards of inquiry, and the like. But, how many managers would have time to read the 17 volumes of the Black Hawk helicopter crash, for example? The Blackhawk helicopter crash is the subject of Chapter 2. Few will ever read such Reports in any detail. Others may read a synopsis or an Executive Summary, or an article published in a newspaper or magazine.
There is an unfortunate heavy reliance on popular media coverage, such as presented by television journalists. To capture the audience’s attention, such coverage all too often is sensationalist and lacking in detail. Television programs can be viewed by millions of people and, no doubt, their opinions about risk and risk management can be swayed as a direct result. In contrast, the numbers of people who actually read ‘the facts’ in the reports of boards-of-inquiry would be very low by comparison, perhaps in the order of hundreds. It is inevitable, therefore, that widely-held views of risk and risk management are themselves at risk of being distorted.