Learning and unlearning from disasters: an analysis of the Virginia Tech, USA shooting and the Lion Air 610 Airline crash

Abstract

The aim of this paper is to explore whether and how far organisations learn from failures. Methods: The paper reviews the current literature about organisational learning and theories of learning from failures, where learning here implies change of practice, and use of modelling techniques to inform recommendations to prevent repetition of similar incidents. Further, it analyses two case studies related to aspects of security and safety: the Virginia Tech Shooting in 2007 and the Lion Air 610 crash in 2018. Both case studies address the concept of learning from failures. In doing so, an analysis of the root causes and vulnerabilities through the methods of Fault Tree Analysis and Reliability Block Diagram is conducted to identify lessons to be learned. Results: Findings are intended to stimulate organisational learning and improve organisational processes to mitigate disasters from happening again. Conclusion: The value of this study is that aspects of learning and unlearning from failures have been identified for the cases used. Expectation for future studies is to extend the proposed methodology to other cases in the fields of surveillance, security and safety.

Behavioral evidence of public aircraft with historical data: The case of Boeing 737 MAX 8 PK-LQP

“…The general process of developing the hypothesis is explained as follows: the first step is to collect relevant material such as the preliminary report of the PK-LQP accident, final report of the PK-LQP accident, online news regarding the PK-LQP accident, press releases from Boeing Company, and Publication Journals/conferences related to B737MAX8. Through these processes, the causes of the accident was mapped following the Fault Tree Analysis of the Lion Air 610 plane crash developed by [18], which informs the second stage -freezing of the findings, as the failure of the Maneuvering Characteristics Augmentation System (MCAS) software, which collects information from the AoA (Angle of Attack) sensor, has been noticed by Boeing [7][9] [18]. Based on these steps, the hypothesis assumes that it would be able to identify evidence by extracting from the historical data of the aircraft.…”

Analysis of noise and bias errors in intelligence information systems

“…Additionally, Huvila et al ( 2021 ) identify safety‐critical environments as an area worth of investigating how information behavior and practice (IBP) and information system development (ISD) can interact. We argue that both safety and security are similar in that they both deal with risk and hazards, and that the main difference between both fields is in the intent (Schmidt et al, 2021 ).…”