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Just like any study, this research has its limitations. It must be emphasized that the conclusion above is tentative, as four factors are found inconclusive. Hence, it is still possible that these factors have played a role in the Safety Region’s decision to not adopt and implement the earlier made recommendations. This is especially true for the barrier of a laissez-faire management style, which concerns the level of pro-active steering by the management on implementing the recommendations, as the Inspectorate’s coordinating researcher noted multiple times the importance of management decisions in this context. Thus, it is for future research to focus specifically on investigating the extent to which the involvement of the management and their decisions is of relevance, as this was beyond the scope of this study.

Furthermore, a number of barriers was selected from the literature on organizational learning and learning from accident investigation reports that appeared to be the most relevant and applicable to this research. This does however not imply that other factors not included in this study could also explain why the Safety Region’s organizational learning process was hindered. One of these factors that surfaced during the interviews could be the severity of an incident, as the operations specialist stated the following:

Operations specialist: “Imagine if there was indeed a relationship between the power outage,

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investigation report] really is about that. However, the fact that this is not the case means that

there is less attention for these reports.”64

Operations specialist: “So it is true that the extent to which the circumstances [of the incident]

actually cause a disaster in society makes a difference in the extent to which investigations are

taken seriously and recommendations are acted upon.”65

These statements indicate that reports and its recommendations are taken more seriously in case of a more serious disaster. The Inspectorate’s coordinating specialist researcher also noted that the accident investigation into the power outage of 2017 was approached and designed differently from the accident investigation into the power outage of 2015, as a link was expected between the power outage and potential casualties in 2017, while there were no injuries or fatalities in 2015. Hence, it is strongly advised to conduct more research into the relevance of the severity of an incident, or the lack thereof, as a barrier to organizational learning from crises and accident investigation reports.

Furthermore, the relatively small number of interviewees constitutes to some extent a limitation to this research as well. Although it can be assumed that the answers provided by the employees of the Safety Region represent the opinion of the Safety Bureau and Safety Region in general, as two other approached employees noted that their stories fully align with the stories of the respondents, the research outcome would have had more validity if these colleagues had indeed confirmed the story of the crisis management coordinator and operations specialist during an interview. Additionally, board members of the Safety Region were not included in the sample due to their busy schedule and the limited time frame of this study. This limited the collection of relevant data, as their perspective appeared important to determine the level of trust in the skills and willingness of the employees and if and to what extent this formed a barrier to organizational learning. Thus, future research would do well in including the perspective of the management of an organization.

Lastly, one must keep in mind that the generalizability of the research is rather limited, as only one case is under investigation. While this research design served the purpose of the research, it is important to acknowledge and understand that the research results cannot simply be applied to other cases. It is therefore recommended that future research explores what barriers hinder organizational learning within other organizations that may have to deal with accident investigation reports. It would

64 _{“Stel je nou eens even voor dat er wel een relatie was geweest tussen stroomstoring, niet/laat opnemen van} de telefoon en overlijden, dan gaat het echt daarover. Het feit trouwens dat dat niet zo is, maakt ook dat er minder aandacht is voor zo’n, voor die rapporten.”

65 _{“Dus het is waar dat de mate waarin, eh, als het omstandigheden feitelijk in de samenleving een ramp} veroorzaken, dat levert wel een verschil op in de mate waarin onderzoeken serieus worden genomen of aanbevelingen worden opgevolgd.”

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for instance be interesting to look into private companies such as, in the case of the power outages, telecom providers. However, even though the external validity of this research is limited, it must be pointed out that this research is able to contribute and generalize to the existing literature. The uniqueness of this single case allowed for exposing and uncovering causal mechanisms that prevented a Dutch Safety Region from learning from accident investigation reports. They might not only serve as building blocks for new theories, but also help both the Inspectorate and the Dutch Safety Regions in gaining a better understanding of the organizational learning process from accident investigation reports and, just as important, each other.

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Bibliography

Analistennetwerk Nationale Veiligheid. (2016). Nationaal Veiligheidsprofiel 2016. Een All Hazard

overzicht van potentiële rampen en dreigingen die onze samenleving kunnen ontwrichten.

Rijksinstituut voor Volksgezondheid.

Argyris, C. (1991). Teaching Smart People How to Learn. Reflections, 4(2), 4-15. Argyris, C. (1999). On Organizational Learning. Second Edition. Blackwell Publishers.

Beer, M., & Eisenstat, R. (2000). The Silent Killers of Strategy Implementation and Learning. Sloan

Management Review, 41(4), 29-40.

Berthoin Antal, A., Lenhardt, U., & Rosenbrock, R. (2003). Barriers to Organizational Learning. In M. Dierkes, A. Berthoin Antal, J. Child, & I. Nonaka, Handbook of Organizational Learning &

Knowledge. Oxford University Press.

Birkland, T. (2009). Disasters, Lessons Learned, and Fantasy Documents. Journal of Contingencies and

Crisis Management, 146-156.

Blatter, J., & Haverland, M. (2012). Designing Case Studies: Explanatory Approaches in Small-N

Research. Palgrave Macmillan.

Broekema, W., van Kleef, D., & Steen, T. (2017). What Factors Drive Organizational Learning From Crisis? Insights from the Dutch Food Safety Services' Response to Four Veterinary Crises.

Journal of Contingencies and Crisis Management, 25(4), 326-340.

Carley, K., & Harrald, J. (1997). Organizational Learning Under Fire. American Behavioral Scientist,

40(3), 310-332.

Cornielje, C., & Bos, J. (2015). Protocol toezicht op de veiligheidsregio's. Den Haag.

Drupsteen, L., & Guldenmund, F. (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.

Easterby-Smith, M., & Lyles, M. (2011). Handbook of Organizational Learning & Knowledge

Management. Second Edition. John Wiley & Sons.

Elliott, D. (2009). The Failure of Organizational Learning from Crisis - A Matter of Life and Death?

Journal of Contingencies and Crisis Management, 17(3), 157-168.

Elliott, D., & McGuinness, M. (2002). Public Inquiry: Panacea or Placebo. Journal of Contingencies and

Crisis Management, 10(1), 14-25.

Inspectie Veiligheid en Justitie. (2013). 1-1-2 onder de loep. Een onderzoek naar de opbouw en

organisatie van het alarmnummer en de storingen in 2012. Ministerie van Veiligheid en

Page 81 of 81

Inspectie Veiligheid en Justitie. (2016). Stroomstoring Noord-Holland 27 maart 2015. Lessen uit de

crisisbeheersing en telecommunicatie. Ministerie Veiligheid en Justitie.

Inspectie Veiligheid en Justitie. (2017). Onderzoek naar de Stroomstoring Amsterdam en Omstreken

17 januari 2017 - Bereikbaarheid en Continuïteit van de Meldkamer.

Jonker, J., & Pennink, B. (2010). The Essence of Research Methodology: A Concise Guide for Master

and PhD Students in Management Science. Springer Science & Business Media.

Kim, D. (1993). The Link between Individual and Organizational Learning. Sloan Management Review,

35(1), 37-50.

Kuznetsov, A., & Yakavenka, H. (2005). Barriers to the Absorption of Management Knowledge in Belarus. Journal of Managerial Psychology, 20(7), 566-577.

Maruster, L. (2013). Qualitative Research Methods. SAGE.

Ministerie van Veiligheid en Justitie. (2013). Brochure Wet Veiligheidsregio's. Den Haag: Ministerie van Veiligheid en Justitie.

Politie, Veiligheidsregio Amsterdam-Amstelland. (2018). Matrix Aanbevelingen Stroomstoring 17

januari 2017.

Schilling, J., & Kluge, A. (2009). Barriers to Organizational Learning: An Integration of Theory and Research. International Journal of Management Reviews, 11(3), 337-360.

Thurmond, V. (2001). The Point of Triangulation. Journal of Nursing Scholarschip, 33(3), 253-258. Toshkov, D. (2016). Research Design in Political Science. Palgrave.

Veiligheidsregio Amsterdam-Amstelland. (2016). Gemeenschappelijke Regeling Veiligheidsregio Amsterdam-Amstelland 2015. Opgehaald van

http://decentrale.regelgeving.overheid.nl/cvdr/xhtmloutput/Historie/Amsterdam/CVDR4027 82/CVDR402782_1.html

Veiligheidsregio Amsterdam-Amstelland. (2017). Stroomstoring 17 januari 2017. Evaluatierapport. Wet Veiligheidsregio's. (2010, February). BWBR0027466. Opgehaald van

http://wetten.overheid.nl/BWBR0027466/2018-01-01

Yin, R. (2015). Qualitative Research from Start to Finish, Second Edition. Guilford Publications.

Appendix I: Interview transcripts

Appendix II: Coding scheme