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Page 2 Schmidt et al. J Surveill Secur Saf 2020;1:1-15 I http://dx.doi.org/10.20517/jsss.2019.02

Keywords: Learning from failures, organisational learning, Virginia Tech Shooting, Lion Air 610 crash

1. INTRODUCTION
Failures are often associated with negative implications and illustrated to be something that should be
avoided in organisations. However, it has been identified that failures can help improve organisational
[1-4]
learning and strengthen an organisation’s resilience . Further, it is argued that organisations learn more
[5]
from failures than successes . However, learning from failures is not always achieved by organisations due
to factors such as denial of failure, issues of ineffective communication and information sharing, status
[6]
quo and lack of corporate responsibility . When failures are not detected in time, they can cause a chain
reaction resulting in a major failure or disaster. Within organisations, these major failures are often seen
[8]
[7]
as Black Swans as their occurrence is low, but their impact is severe . According to Fortune and Peters ,
failures that have such a destructive impact that they receive widespread media attention and investigation
are considered disasters. These impacts are not limited to a number of fatalities and casualties but also
[9]
related to the wider influence on for example economies, policies and communities. Knight and Pretty’s
seminal work demonstrated a clear link between an organisation’s positive handling of a failure and the
potential increase in cumulative annual returns, suggesting a further financial imperative to encourage
organisations to better engage with learning from failure. The aim of this paper is to explore whether and
how far organisations learn from failures. The main contributions of this paper are two-fold: First, we
demonstrate that a common modelling set of tools can be applied to completely different disasters chosen
from the two domains of safety and security. Second, we present a taxonomy of failures classification and
the role of mental modelling in learning from failures.

2. METHODS
Following the Introduction, the paper reviews the current literature on organisational learning, learning
and unlearning from failures as well as explaining failure theories. The paper then analyses two case studies
related to aspects of security and safety: the Virginia Tech, USA shooting in 2007 and the Lion Air 610
crash in 2018. Both cases have been chosen to compare efficient learning from failures versus inefficient
learning from failures. Further, they have been selected to demonstrate the framework of learning from
[1]
failures introduced by Labib and Read , which addresses three aspects: the aspect of feedback from users
to design (i.e., change the status quo), the incorporation of failure analytical tools (new mental models) and
the generic lessons learned (i.e., isomorphic learning), highlighting the wider applicability of the approach,
independent of industry or event type. The paper concludes with a discussion and a summary.

[10]
The case studies are following the framework of Labib by first introducing the case and sequences that
resulted in the disaster. After the technical cause and logic of the failure is assessed and consequences
addressed, methods such as the Fault Tree Analysis (FTA) and the Reliability Block Diagram (RBD) are
used to identify the causes and the vulnerability factor. The case studies are concluded by recommendations
and identification of generic lessons to support organisational learning from failure.

2.1 Organisational learning and unlearning
Learning is an important aspect of life as it is can stimulate change and improve actions through better
[11]
understanding and knowledge . This approach not only influences individuals but also organisations.
Organisational learning implements the standard definition and applies it to a wider context. Since the
1980s, the idea of organisational learning has flourished, with numerous definitions and studies into
the concept . According to Toft and Reynolds , organisational learning is seen as a process in which
[12]
[13]
individuals in an organisation continuously reflect upon and reinterpret their working environment and
the experiences encountered in order to improve actions. This definition was supported by Madsen and