Team, Individual, and Organizational Learning from Experience in Two High-Hazard Industries

卡罗尔高危行业，如核电和化工加工厂，需要学习和改进，而不是仅仅依靠反复试验，因为严重的事故代价太高，也太危险。这些行业已经将相当多的注意力和资源放在从运营经验中学习，包括交流最佳实践、同行审查和自我评估。然而，经常有改进或持续改进的失败，要么是因为问题被误解了，要么是因为变革没有得到有效实施。这个研究项目的重点是开发一个由四个核电站和两个化工厂的数十个事件审查小组组成的数据库。这些团队由来自运营、维护和工程等多个小组的代表组成，在发现严重问题或性能趋势后立即进行。这样的团队努力每年都是为最重要和最复杂的问题而保留的。每个团队负责收集和分析信息，然后针对工厂设备、程序、培训、组织等方面的变化提出建议。使用来自团队成员和经理的一系列问卷，他们是报告的发起人或接收者，并直接观察团队的行动，我们解决了团队、个人和组织级别上的几个相互关联的问题。在集团层面，我们希望了解如何将正确的专业知识和认知能力结合在一起，以便在团队完成工作后，在团队成员中产生更有效的报告和更多的学习。在个人层面上，我们希望了解参与事件审查团队如何使团队成员对自己和他人的工作更加深思熟虑，并使他们的思维更加复杂。在组织层面，问题是工厂改进如何取决于团队报告的性质以及管理层和工厂员工对报告的接受程度。希望为高风险行业的管理提供新的理论和实践资料。

Carroll High-hazard industries such as nuclear power and chemical process plants need to learn and improve without sole reliance on trial-and-error, because serious accidents are too costly and dangerous. These industries already place considerable attention and resources on learning from operating experience, including exchange of best practices, peer reviews, and self-assessment. Yet there are frequent failures to improve or to sustain improvement, either because problems are misunderstood, or because change is not implemented effectively. This research project focuses on developing a data base of several dozen incident review teams in four nuclear power plants and two chemical plants. These teams are composed of representatives from multiple groups such as operations, maintenance, and engineering, immediately following discovery of a serious problem or performance trend. Such team efforts are reserved for the most important and complex concerns each year. Each team is responsible for gathering and analyzing information and then making recommendations for changes in plant equipment, procedures, training, organization, and so forth. Using a series of questionnaires from team members and managers who are the sponsors or recipients of reports, and direct observation of teams in action, we address several interrelated issues at the group, individual, and organizational levels. At the group level, we would like to understand how to put the right expertise and cognitive abilities together in order to produce a more effective report and more learning among the team members that is diffused across the plant after the team has completed its work. At the individual level, we would like to understand how participation on an incident review team makes the team members more thoughtful about their own and others' work, and more complex in their thinking. At the organizational level, the issue is how plant improvement depends upon the nature of the team report and its reception by management and plant employees. We hope to develop new theories and practical information for management of high-hazard industries.