Learning from Disasters: Why Is It So Hard?

The heart of this essay is a small study of four investigation reports, two from Holland and two from the United States. Based on this study we ´11 present a fairly simple typology of approaches by investigators for interpreting the facts that they find. From the perspective of a manager that made a decision that proved to be disastrous we´ll explain the strengths and weaknesses of these approaches for learning. From the perspective of the investigator we´ll explain the logic of these approaches. Confronting both perspectives with each other explains why it is so hard for managers to learn from investigation reports.