Crisis induced learning within Safety Regions A case study of the Chemie-Pack and Chemelot cases
Daphne Blanker S2264803 Universiteit Leiden Supervisor: Dr. Broekema Second Reader: Dr. Kuipers
18-8-2019 Words: 23.639
Table of Contents
1. Introduction 4
2. Literature 7
2.1 Organizational Learning: The Concept and the Beginning 7
2.2 Crisis Induced Learning: What is a Crisis? 9
2.3 Crisis Induced Learning: Importance and the creation of Artefacts 11
2.4 Crisis Induced Learning: the difficulties 14
3. Explanatory Factors for Crisis Induced Learning 17
3.1 Leadership 18
3.2 Organizational Structures 20
3.3 Media Attention 25
4. Methodology 28
4.1 The design of the study 28
4.2 Case Selection 29
4.3 Data Collection, Analysis and Measurement 31
4.4 Limitations of the Study 32
4.4.1 Validity and Reliability 32
5. The Cases and their Backgrounds 34
5.1 Case 1: The Chemie-Pack Fire 35
5.2 Case 2: The Chemelot Incidents 37
6.1 Case 1: The Chemie-Pack Fire 40
6.1.1 The Role of Leadership Styles 40
6.1.2 The Role of Organizational Structures 45
6.1.3 The Role of Media Attention 50
6.2 Case 2: The Chemelot Incidents 59
6.2.1 The Role of Leadership Styles 59
6.2.2 The Role of Organizational Structures 61
6.2.3 The Role of Media Attention 65
7. Discussion and Conclusion 72
References 77
1. Introduction
In the Netherlands in 2018, 71 people died as a result of, or in an occupational accident (NOS, 2019). As explained by the inspectorate SWZ of the Ministry of Social Affairs and Employment this is an alarming number, as in 2017, 54 people died as a result of an occupational accident (NOS, 2019). An important sector of the Dutch economy in which occupational accidents can have grave consequences for employees and their surroundings is the chemical industrial sector. In order to prevent future accidents or disasters is it important to learn from these past moments of crises. Companies that play a vital role in the disaster management of these crisis situations are the Dutch safety regions. Understanding whether safety regions learn from past mistakes could be vital for the prevention of future dangers or even disasters. This thesis hence focusses on two important cases that have taken place in the industrial sector in the Netherlands. One is the fire at Chemie-Pack near Dordrecht on the 5th of January 2011 and the other are several incidents grouped as one, one with a fatal ending, at Chemelot near Geleen during the year 2016. This thesis will investigate whether crisis induced learning has taken place concerning the veiligheidsregio’s1 in the Chemie-Pack fire and the Chemelot incidents in 2016 with a more
specific focus on fire brigades. Fire brigades have been specifically selected for this thesis as fire brigades have been heavily involved in both the Chemie-Pack fire and the Chemelot incidents of 2016. Another reason for selecting safety regions and fire brigades as a part of this study is that many reports focus on the companies at which the fires originate, rather than those who handle
1 Safety Regions, in Dutch, Veiligheidsregio’s, are clusters of several emergency services, organized per municipality or region. The total amount of safety regions in the Netherlands is 25. Their tasks consist out of disaster and crisis management; firefighting; proving medical aid; and peacekeeping. The current safety regions correspond with the former police regions, which have now been integrated within the safety regions.
the emergency situation. By conducting this study, this thesis aims to shed more light on the actions and learning patterns of safety regions and fire brigades in industrial related incidents. By doing so, this thesis wants to fill a niche within the subject of crisis induced learning.
Due to the difference in size and impact, will the Chemie-Pack fire be analyzed as a single case, while the Chemelot analysis will consist out of multiple cases2. For Chemelot, several incidents
in 2016 have been grouped together. This has been done as this thesis expects that a combination of these events can be seen as a crisis comparable to that of the Chemie-Pack fire. Several incidents that occurred on the Chemelot terrain in 2016 are hence viewed as one large crisis, comparable to that of the Chemie-Pack case. The incidents that occurred at the Chemelot terrain also happened shortly after one another. Hence, this thesis will assume that learning has not taken place in between the incidents at Chemelot. Another reason to support this idea is the fact that official reports only exist on all accidents in 2016, rather than one for every single incident. From henceforth, the multiple Chemelot cases will be viewed as one case in the remainder of this thesis. As both cases can be compared in this manner, this study wants to investigate whether similar levels of crisis induced learning can be found in both cases. It is expected that the following explanatory factors will have an influence on crisis induced learning: (1) Leadership Type, (2) Organizational Systems, and (3) Media Attention. This expectation has been created based on studies by Deverell (2009 and 2010) who deemed media attention as an important factor for crisis induced learning. Leadership and Organizational Structures have been added as explanatory factors out of personal interest. These factors have however been discussed with the supervisor and have been motivated by large amounts of research. The connection between crisis
induced learning and the previously mentioned explanatory factors therefore leads to the
following research question: ”How do (1) Leadership Style, (2) Organizational Systems, and (3) Media Attention affect crisis induced learning in the Chemie-Pack and the Chemelot case?”. Leadership Style can be defined as the following: “Leadership is the accomplishment of a goal through the direction of human assistants. A leadership style is the way in which one successfully marshals his human collaborators to achieve particular ends.” (Prentice, 1961: 143, in
combination with personal adaption). Organizational Systems have been defined according to the definition of Mintzberg (1979: 2): “The sum total of the ways in which it (the organization) divides its labor into distinct tasks and then achieves coordination among them”. Lastly, Media Attention has been clarified as the following: “The way in which communication channels and social media networks provide information or updates on a certain subject or object. These kind of updates and information can be delivered through broadcasting, newspapers, magazines, TV, radio, billboards, direct mail, telephone, fax and internet”. All definitions can be found in table 1. The complete background and aspects of each explanatory variable will be highlighted in chapter 3.
The following parts of this research will explore the theoretical framework of crisis induced learning by summarizing its main points in a literature review. The origins and the different parts of crisis induced learning will be mentioned and discussed. Furthermore, will the literature review explain the link between crisis induced learning and the three explanatory variables. After this has been established will the three explanatory variables be explained, including their
dimensions and aspects. The following section will discuss the methodology of the thesis. This part will touch upon the design of the study, methods of data collection, analysis of the data and possible concerns with validity and reliability. After the methodology has been explained will the
two different cases be illustrated in detail. The sixth part of this thesis will focus on the analysis of the three explanatory variables, how these can be connected to the cases and what this connection would mean. The last parts of this thesis will consist of the discussion and conclusion. The discussion will link the theory back to the results, while the conclusion will discuss the final conclusions that have been reached in this research.
2. Literature
2.1 Organizational Learning: The Concept and the Beginning
Recent changes in business environments have inspired managers to search for new ways to keep adapting and changing their businesses (Tabrizinia, 2016; 635). These changes have reignited the spark for managers and others to understand the concept of organizational learning. This
development has brought about a change in which managers are seeking to survive turbulent times and complicated operational environments through continuous organizational learning (Noruzy et al., 2013). Before we discuss some developments within organizational learning, it is important to explain the concept itself. Dekker and Hansén (2004,: 216) state that:
“ Organizational learning theory is recognized as a fruitful way of explaining the relation between information and knowledge and organizational behavior and change” (Deverell, 2010; 36).Dixon (2017) on the other hand, explains the notion of organizational learning as the following: “the intentional use of learning processes at the individual, group and system level to continuously transform the organization in a direction that is increasingly satisfying to its stakeholders” (p. 12). Due to its complicated nature, organizational learning is not be confused with the learning organization. A learning organization is different, as King (2001: 14) explains
that: “A learning organization may best be thought of as one that focuses on developing and using its information and knowledge capabilities in order to create higher-valued information and knowledge, to change behaviors, and to improve bottom-line results”. The difference between the two concepts is well explained by Yeo (2005: 369): “organizational learning is used to refer to the process of learning while the idea of “learning organization” refers to a type of
organization rather than a process”. Academics who have studied organizational learning seem to agree that this type of learning includes both cognition (renewing the states of knowledge) and behavior (a shift in the organizational result) (Fiol and Lyles, 1985:803; Argyris and Schön, 1974; Carley and Harrald, 1997). Those who want to learn from the process, also called learning agents, need to grasp what they previously did not understand. Afterwards, they need to act upon this new understanding in order to prevent the previous mistake from taking place again
(Deverell, 2010: 36). A change in the cognition and behavior of the learning agent could hence result in a situation in which organizational learning can take place. Argyris and Schön explain in one of their books that this learning can take several forms. One of the most well-known kinds of this learning process is that of single and double loop learning (Greenwood, 1998: 1048). In a single loop learning model, an organization continues to pursue its present objectives and policies, while the double loop learning model “leads to the organization modifying its underlying norms, policies and objectives” (Korth, 2000: 87).
By understanding how the basics of organizational learning work, one can see the importance of organizations and how communication within such a structure is of great value. In order to understand what went wrong in a specific situation, parts of an organization need to
communicate and learn from one another. This communication is vital as it could aid in solving the previously identified problem. It is hence essential to understand how different parts of a
structure cooperate with each other and learn from common problems. That is why this thesis wants to focus on how the structure of an organization can contribute to a learning process. Different from organizational learning however, will this thesis investigate how organizational structures can have an effect on crisis induced learning. The next section will discuss the topic of crisis induced learning more in depth by explaining what a crisis actually is.
2.2 Crisis Induced Learning: What is a Crisis?
A section of organizational learning that focusses specifically on crisis events is that of crisis induced learning. Before we specify what crisis induced learning is, it is important to understand the definition of crisis. According to Broekema (2018: 14), Rosenthal et al. (1989) explain a crisis as the following: “a non-routine situation in which the core interests of a society are under severe threat with potentially devastating consequences”. Deverell (2010) adds that “Crises challenge organizational behavior, structures and cultures, as day-to-day organizational
operations and procedures are pushed to the limit and dilemmas are brought to a head” (Deverell, 2010; 32). Recent events such as Hurricana Katrina in 2005, the Australian bushfires in 2009, the Fukushima nuclear crisis in 2011, the MH17 plane crash in Ukraine in 2014 and the earthquake in Nepal in 2015, are all classified as either a crisis, disaster or incident (Broekema, 2018; Deverell, 2010). It is important not to confuse a crisis with an incident or a disaster, as these terms can have completely different meanings. The difference between the three terms is well explained by Broekema (2018) who indicates that “Crises differ from incidents and disasters in that incidents are disruptions with less potential loss and scale and can be dealt with by the normal system, but which, if not contained, could escalate into a crisis, while a disaster can be understood as a ‘crisis with a bad ending’ (Boin & Rhinard, 2008, p. 3; Perry and Quarantelli,
2005).” Seegers however raises an important point, stating that even though the sizes of disasters, crisis and incidents could vary, their effects can be similar. Even though incidents or smaller events might not have the same scope as disasters and crises, incidents could affect the public’s view of the government, organizations or other authorities (Seeger et al, 2003). The impact of incidents should therefore not automatically be underestimated when compared to disasters or crises.
The current scale of crises has caused crisis induced learning to become an important component of organizations dealing with crises and crises-related incidents. Because organizations and disasters are becoming more complex, the learning rate of organizations might determine their chances to survive (Schwandt & Marquardt, 2000). Due to this change, constant learning has become a necessity for most organizations and institutions instead of just a reasonable option (Barnett & Pratt, 2000; Mitroff, 2005; Ulrich & Jick, 1993). Experts on the topic of crises often agree that modern day crises are mostly of a complicated and multifaceted nature. These crises can be technically complex, have increased media use, have multiple actors involved, and the event itself often has a large impact on different aspects of society (Ansell et al., 2010). Brändström et al. (2004) add that at the heart of a crisis there is a certain unacceptability. This unacceptability should motivate actors and organizations to prevent possible reappearance of the crisis or disaster. The unacceptability of a crisis is however often highlighted through media operations. During a crisis or disaster, media often report regularly on the situation or send out a live feed of the ongoing event. Disaster locations are shown on television and on social media platforms do individuals discuss the ongoing events. Through the reporting of crisis events can media attention highlight the negative points of a crisis. In this way is media attention able to highlight the unacceptability of a crisis. Ma (2005; 1) highlights the importance of media in crisis
situations by stating: “Overall, media reporting plays a key role in the perception, management and even creation of crisis”. Others such as Deverell (2009; 186) have also investigated the effect of media attention on crisis induced learning and have shown that “external critique clearly matters”. Although connections between crisis induced learning and media have been made by Deverell (2009), this study wants to research whether a similar situation would occur in Dutch cases. This thesis therefore aims to investigate what effect media attention can have on a crisis. More specifically, this thesis wants to study whether media attention can influence crisis induced learning within emergency organizations.
2.3 Crisis Induced Learning: Importance and the creation of Artefacts
While the last section spoke more specifically about the definition of a crisis and what is of importance during such an event, this section will highlight the topic of crisis induced learning. Due to the fact that crises have become interdependent and are embedded in so many aspects of society, the urge and necessity to learn from these events has become critical. Procedures and routines during crises events should be studied in order to improve our understanding of these events. By doing this, both scholars and organizations could learn “how to effectively plan for crises, act during them, and learn from them” (Deverell, 2010; 28). A way in which these routines and procedures are led is often through a protocol in combination with a form of
leadership. Deverell (2009) states that it is important to study crisis events as this could improve actions during a new crisis event. Steps and actions during a crisis are often led by a person at the top or a leader of some kind. It is hence interesting to wonder whether the type of leadership could possibly be of importance for a crisis and its learning process, as this could influence the
way in which people act during a crisis. Scholars such as Janis (1989: 4) seem to support this idea by mentioning the following example.
“Some of the causal sequences that lead to defective policymaking procedures in government, business firms, and public welfare organizations are well known to practically all executives. For example, when a chief executive is provoked to anger or becomes extremely apprehensive or extremely elated in response to a sensational event, he or she might decide impulsively to make a drastic change in policy while dominated by the mood of the moment, without consulting any advisors who could point out flaws and suggest better alternatives to be considered.” (Janis, 1989: 4).
While this excerpt seems to speak of executives and policymaking procedures, similar situations could take place during emergency situations and their protocols. As explained by Janis, the personal reaction of a leader could lead to a certain outcome in a particular situation. Similarly, to people and their characters being different can leadership styles differ per person. The type of leadership or “reaction” during a crisis could thus have an effect on the outcome of a crisis. This thesis hence wants to investigate whether leadership styles can have an influence on crisis situations and its learning process. Even though leadership styles are likely to have an effect on the progression of a crisis, leadership styles cannot stop a crisis from taking place. The reason why an individual or a group of individuals cannot stop a crisis from occurring relates once again back to the issue of how a crisis is interconnected with other fields. While organizations and scholars should have figured out a way to plan for crisis events, they continue to struggle with the real-life effects of crises. Research seems to suggest that politicians, officials and
organizations time and again “fail to meet the public demands” when a crisis hits (Deverell, 2010; 21). Such a situation can occur as citizens might not understand why a certain plan was not
put in place after a crisis has unfolded. For citizens, the results of the crisis have already
unfolded while organizations, such as the government, had to anticipate this result. It is however incredibly hard to anticipate the result of a crisis if a crisis can be interdependent to so many different fields. While governments or organizations might focus on protecting one
interdependent field, another non-anticipated interdependent field might become affected by the crisis. As this problem continues to exist, scholars and organizations are aiming to find a solution to this problem. It is important to note that some scholars such as Deverell (2010) suggest that one can only prepare themselves for a crisis by learning from a previous one. It is hence that Deverell (2010) indicates that a common assumption on crisis and learning is that “preservation trumps” are created in the aftermath of a crisis (See also: Boin, McConnel and ‘t Hart (2009); Dekker & Hansén, 2004; Bannink & Resodihardjo, 2006). Argyris and Schön (1978) add that learning from failures and disasters is essential for companies, as it aids them in creating safe and dependable organizations. Learning from past crises can therefore create a learning structure in which organizations are prevented from making the same mistake again (Argyris & Schön, 1978; 5). A possible method of preventing these mistakes from reoccurring is by reviewing them. In such a review, the key problems are addressed, and new insights are shared that could prevent similar crises in the future. A learning structure like this is often captured by writing a report on the situation in which the past events are reviewed in high detail.
In relation to this type of reviewing, do Elliott and Macpherson explain that after a crisis, a process of knowledge transfer can exist. This process entails that lessons drawn from the crisis are translated into reports or artefacts. Artefacts is a grouping term used by Elliott and
McPherson to group all different kinds of knowledge transfers. As this knowledge transfer often occurs through reports, books and reviews, these items are viewed as objects of knowledge
transfer that are left behind, hence the term artefacts. Through the use and availability of these artefacts are institutions able to institutionalize this learning (Elliott & Macpherson, 2010). Artefacts such as reports on crises or incidents represent the knowledge that is already present within the organization. They can function as such, as the artefact’s identification of problems can be seen as knowledge or information about that specific event. This knowledge or
information can then aid future crisis or disaster planning. These artefacts hence function as a form of knowledge for future events. By writing these artefacts and by identifying the problems within a crisis, an organization can start the process of knowledge transfer or learning. The process of writing artefacts can be viewed as learning as the review of the previous mistakes leads to new insights and, possibly, new strategies for the future. The artefacts that are created after a crisis thus function as a handbook of how issues should be handled and represent the existing knowledge within an organization (Engeström & Blackler, 2005). This study tries to understand crisis induced learning in relation to three explanatory variables by reviewing artefacts of the Chemie-Pack and Chemelot case. In this study, the utilized artefacts are official reports on both cases.
2.4 Crisis Induced Learning: the difficulties
The previous parts have touched upon the various aspects of crises and its learning process. As crisis induced learning is still a relatively new field, many issues with the subject have not been solved. This paragraph hence wants to highlight some of the difficulties associated with crisis induced learning and where they stem from. One of these issues is that the theory on crisis and learning is underdeveloped and that the relation between the two notions is not understood very well in the literature (Carley & Harrald, 1997: 317, Boin, 2006). A common understanding of
crisis induced learning is still lacking. Opinions are divided on the definition of crisis induced learning and how learning and crisis relate to one another. Boin et al. (2005; 134) even state that the relationship between crisis and learning has not been clarified to a satisfactory level.
Nohrstedt (2007; 7) seems to agree with this point, as, in one of his studies, he draws the attention to the fact that it is still unknown, why and how some organizations and individuals learn in the wake of a crisis. It is important that this relationship should be illustrated clearer in the future. This is necessary in order for research on crisis induced learning to be more concise and relevant to its field. Especially in the field of crisis is it important that the relationship between a crisis and its learning moments can be recognized. Being able to distinguish this pattern could possibly aid the development of crisis plans or could partially prevent future crises. Pearson and Mitroff (1994) can perhaps be linked to as why information on the relationship between crisis and learning seems to be lacking. One of the points raised in their article is that crisis management has been a field that has only gained attention in the last few years, meaning that much information still needs to be uncovered and written about (Pearson & Mitroff, 1993). Due to the lack of information on the general subject are researchers unable to connect crisis and learning in an adequate way. This is not yet possible as not enough attention has been paid to how crisis management functions. One needs to understand how the field of crisis management works before one can apply crisis induced learning to it. Hence, because the information on crisis management is still lacking, scholars are not able to get clear grasp of what crisis induced
learning actually is.
Mitroff however is under the impression that even more problems than the previously mentioned ones can be connected to crisis induced learning. In a study which was conducted together with Alpaslan and Green does Mittrof state that the literature on crisis management has not been able
to construct adequate structures for studying crises (Mitroff, Alpaslan & Green, 2004: 175). This inadequate structure for studying crises might be caused by the nature of crises. As explained before, crises are involved with different core aspects of a society. Because these core aspects differ so much, and are often not related, a clear structure to solve crises is often lacking. This explains why Mitroff, Alpaslan and Green (2004) state that “crisis management researchers deal with a set of highly ill-structured, interactive and interdependent problems.” (Deverell, 2010; 28). Because crises often compromise of different fields, the problems that occur are in many cases interdependent or interactive. Solving them requires a well-defined structure, as the different fields of the crisis may have an effect on one another. It is hence important to know what the result of a certain strategy will be. A specific solution to a crisis might work in one field when it could cause problems for another. The creation of a well-designed crisis management structure is however very hard as there are endless possibilities of interdependent and interactive fields when it comes to a crisis. Predicting the outcome of a crisis for an interdependent field is nearly impossible. Hence, creating a structure that would work in multiple crisis related
occasions seems incredibly problematic. Going from the fact that many crises can be interactive or interdependent, one would think that much attention would be paid to this issue. The opposite however seems to be true. Although awareness on the effects of crises has become more
prominent, real life crises often prove that organizations are not prepared for the crisis at hand (Fegley & Victor, 2005; Pearson, 2002). Lagedec (1997) adds that organizations with a crisis plan often still do not know how to act when faced with a crisis. A combination of both factors might be able to explain why organizations are unable to act accordingly to a crisis situation. It is evident that the link between crisis and learning needs to be clarified further. This is necessary in order to solve the other remaining issues that are linked to this core problem
3. Explanatory Factors for Crisis Induced Learning
The explanatory factors that are expected to have an influence on crisis induced learning are qualified as the following: (1) Leadership Type, (2) Organizational Systems and (3) Media Attention. This thesis will rely on the hypothesis that the explanatory factors as mentioned in this thesis will have an effect on crisis induced learning. This is expected as these variables are deemed as key features that influence learning during crisis events. It is hence anticipated that signs of these factors can be found within in the examined artefacts.
Because this thesis deems artefacts as signs of crisis induced learning, the following self-formulated definition of crisis induced learning will be used as a definition of crisis induced learning in the remainder of this thesis: “All tangible and purposely written down artefacts that are created in the wake of a crisis event for clarifying and/or learning purposes.” This thesis would find that a purposely written down effort can be defined as the creation of an artefact. Examples of artefacts used in this thesis are the official reports written on the Chemie-Pack and Chemelot cases. These reports can be viewed as artefacts as was explained in chapter 2.3. It is however important for this thesis to make a distinction between written down artefacts and purposely written down artefacts. If the latter wording had been used, mere scribbles on both cases could have possibly been viewed as signs of crisis induced learning. This thesis assumes that crisis induced learning can only be found in purposely written artefacts. The reason for this is that these documents have been carefully constructed and have been checked on their validity. Additionally, are artefacts, such as reports, documents that are construct with an educational or clarifying purpose in mind. The personal scribbles of an employee on a crisis have not been validated and are more often created for personal use. Moreover, were these kinds of written down efforts excluded from the definition as it would have been impossible to check these.
Official reports on both cases have hence been used as artefacts in this analysis and will be utilized in a large part of this thesis.
3.1 Leadership
The first explanatory variable used in this study is important to assess the probability of crisis induced learning as Graham and Nafukho (2007) state that leadership is a top down process that can influence all members of an organization to become both learners and teachers. The
generation of more learners in an organization could be beneficial for crisis induced learning. A certain leadership style could hence influence the creation of learners within an organization. The following definition of leadership style will hence be used in the remainder of this thesis:
“Leadership is the accomplishment of a goal through the direction of human assistants. A leadership style is the way in which one successfully marshals his human collaborators to achieve particular ends. ” (Prentice, 1961: 143, in combination with personal adaption).
The selected reports on both cases will be checked for the presence of a specific leadership style that corresponds with one of the dimensions, as mentioned further on in this section. This will be done by relating the leadership styles in the reports to the selected leadership styles. In order to meet the criteria for a certain leadership style, the statements made about leadership styles should show clear signs of one of the types of leadership. If they do not meet these criteria to a large extent, the leadership style will remain undecided. This will be done in order to prevent overgeneralization of the leadership styles. If the leadership style of a case does not meet the qualifications for a certain type of leadership, the leadership style will remain inconclusive but will be discussed. The criteria for the specific leadership styles have been added in table 1 and will be shortly explained in the next section. This thesis will focus on the following two kinds of
leadership and their corresponding theories: (1) Autocratic/Authoritarian Leadership and (2) Laissez-faire/ Free-rein Leadership. These two theories were selected to include two opposite schools of thought. While the autocratic theory focusses on the more traditional view of
leadership, the laissez-faire theory takes a more modern approach. With a more traditional view on leadership is meant that this style of leadership is more of a top down process in which the leader is in charge of its subordinates (De Cremer, 2006: 81-82). In this process does the leader make the decisions and does he or she direct its subordinates to their activities (See also: Peterson, R. S. (1997). A directive leadership style in group decision-making can be both virtue and vice: Evidence from elite and experimental groups. Journal of Personality and Social Psychology, 72, 1107–1121; and Lewin, K., Lippit, R., & White, R. K. (1939). Patterns of aggressive behavior in experimentally created social climates. Journal of Social Psychology, 10, 171–199). This kind of leadership means that directions flow from the top and that there is little room for subordinate authority or that decisions are made by one individual rather than a group. The laissez-faire leadership on the other hand is deemed a more modern approach, as differences between the leaders and its subordinates are less evident. In this leadership style does the leader not necessarily lead in every sense, as leaders communicate decisions with their subordinates. Sometimes, laissez faire leaders leave decisions up to their subordinates, something which would never occur in the autocratic leadership style. Laissez-faire leadership is a more inactive form of leadership (Jones & Rudd, 2008: 91). Jones and Rudd (2008) state that this leadership style is known for its reluctance to be actively involved. The reluctancy to be involved is motivated by the idea that the best kind of leadership is created through disassociating oneself from the process. Another sign of laissez-faire leadership is that decisions are delayed and that
their views on issues, nor do they take control of the actions of the followers. Hence, Northouse (2004) calls this kind of leadership a “hands-off” type of leadership. Decisions are therefore left to the followers, as the laissez-faire leadership assumes that followers should be intrinsically motivated to reach certain goals or ideals (Jones & Rudd, 2008: 92).
It is expected that an autocratic leadership style will have a neutral or negative effect on crisis induced learning. This is assumed because autocratic leadership is arranged in a clear and concise way. With this is meant that in an autocratic leadership style it is known who is responsible for what and who should make a decision on a certain subject. This thesis hence assumes that the made decisions are likely to be good or neutral for the crisis situation. This would be likely as the people in charge have likely been selected for their capabilities. Because leaders have been carefully selected for this position, they could be less likely to make mistakes. If less mistakes are being made through an autocratic leadership style, few points would remain in which organizations could learn from crisis situations. It is hence also assumed that the unclear division of (leadership) tasks in the laissez-faire leadership style will lead to more mistakes and thus more crisis induced learning.
A summary of the explanatory factor leadership style and its corresponding dimensions and definitions can be found in table 1.
3.2 Organizational Structures
The second variable relies on the structures within or between organizations and how the people within these structures are able to communicate, collaborate or interact with one another. By researching structures, this thesis wants to investigate how different parts of an organization cooperate and collaborate with one another. Through assessing the dynamics of structures within
an organization, the success of evaluative inquiry efforts can be measured (Preskill & Torres, 1999). The success of this evaluative inquiry can again be an indicator for learning, as groups have to improve their collaboration skills to move forward. It is hence interesting to research how people within these structures can contribute to learning. In large scale operations such as crisis events, are multiple parts of organizations involved to solve the crisis. In such an event is the communication between the different parts of an organization of great importance. The way in which information flows through different parts of an organization could have an impact on how the organization deals with the crisis. Moreover, is it expected that the connection between the different structures could have an effect on learning. This is presumed as, leadership style can in some way be compared to organizational structures. Similarly, to leadership styles do groups of people, or organizational structures, have an impact on how information is processed and distributed. While leadership style focusses more on the individual level, relating from a leader to a subordinate, the organizational structure level operates on a group level. In an organizational system do parts of the structure, such as management departments, rely on the information from another group, the everyday employees. By focusing on how people function within a structure, this thesis wants to get more insight on how different groupings of people can process, and learn from, crises events. In order to analyze this communication process in an adequate way, people within an organization are studied on a more individual level by looking at leadership styles, while organizational structures was added in order to investigate how people can influence, and learn from crisis events, in groups, block or departments. To assess the kind of structures present in both cases, this thesis will draw on important existing structure theories. The dimensions that have been selected for this thesis stem from the work of Henry Mintzberg. This is additionally the reason why the definition of structures has been selected from Mintzbergs work. Mintzberg
defines structures as the following:
“
The sum total of the ways in which it (the organization) divides its labor into distinct tasks and then achieves coordination among them” (Mintzberg, 1979: 2). This definition will once again be used as the definition of structures in the remainder of this thesis and can be found in table 1.In his work, Mintzberg addresses several different theories on organizational structures within companies or institutions. From all these theories, three have been selected. These specific three have been selected as they a could be found in both, or either of the case studies. In order to maintain variety, the theories that have been selected are on different spectrums of theories on organizational structure.
The first organizational structure theory that has been included in this study is the simple structure theory. Mintzberg explains that in this structure, decisions are often made in a
centralized way by chief executive officers. Grouping of employees or units, if it occurs, happens mostly on a loose and more functional basis (Mintzberg, 1980: 331). The communication flow of this structure is very informal with a similar regard to the decision making (process). The use of a centralized power creates possibilities for swift responses (Mintzberg, 1980: 331). Mintzberg (1980: 331) adds: “Another condition common to Simple Structure is a technical system that is neither sophisticated nor regulating”. A Simple Structure is most often registered in young and small organizations. This tends to be the case as they did not have the time yet to expand to larger bureaucratized institutions or companies (Mintzberg, 1980: 331-332).
The second structure theory of this thesis is the Machine Bureaucracy theory. This specific structure is one that is often found in mass production firms, government agencies and “organizations that have special needs for safety, such as airlines and fire departments.” (Mintzberg, 1980: 333). The theory makes a sharp distinction between line and staff as the
machine bureaucracy relies on “the standardization of work processes for coordination”
(Mintzberg, 1980: 332). In this structure, many analysts who are involved with the standardizing process, are considered to be a vital part of the organizations structure (Mintzberg, 1980: 332). Due to the developed power of these analysts, a limited horizontal decentralization occurs. In order to maintain this structure, rules and regulations are considered to be highly important. Formal communication is often the preferred kind of contact and formal decision making usually follows the “formal chain of authority” (Mintzberg, 1980: 332). Regarding the environmental requirements of a Machine Bureaucracy, Mintzberg (1980: 333) states: “-the Machine
Bureaucracy responds to a simple, stable environment, and in turn seeks to ensure that its environment remains both simple and stable.”
The last structure theory is vastly different from the former two and has hence been included in this thesis. This specific theory is distinctive from the former ones in the sense that it is very incompatible with the classical ideas of management (Mintzberg, 1980: 337). This kind of structure is introduced by Mintzberg under the name adhocracy. In an adhocracy, the lines between staff and line are blurred, as staff receives quasi-formal authority. Strategy is hence not imposed from higher ranking employees, but strategy is created by everyone involved with the company (Mintzberg, 1980: 337). An Adhocracy thus often occurs in environments that are multifaceted and dynamic in nature. The danger of Adhocracies is however that they are very vulnerable and often short-lived. Uncertainty tends to be a large part of this theory, which leads to the fact that young Adhocracies often evolve themselves into bureaucratic systems to avoid the uncertainness (Mintzberg, 1980: 338). Adhocracies have become more common since the end of World War Two and have developed themselves into a modern form of structural management
(Mintzberg, 1980: 338). Lastly does Mintzberg specify that adhocracies are not common in a certain or specific area of business or institutions.
It is expected that the safety regions will have an organizational structure similar to that of the machine bureaucracy. This is expected as safety organizations often follow the organizational structure of a machine bureaucracy. It is also expected that the presence of a correctly executed machine bureaucracy will have a neutral effect on crisis induced learning. Similarly, to the argument raised in the first expectation, is the expectation that a machine bureaucracy will lead to less mistakes during a crisis. This is assumed as a machine bureaucracy has standardized tasks which are organized in a highly structured way. It is hence expected that if this organizational structure is followed, less mistakes will be made. In addition to this is it assumed that signs of an adhocracy will lead to more crisis induced learning. This is expected as an adhocracy has a less clear division of tasks. Risks of wrong decisions are deemed as greater as staff and line are both involved in the creation of strategy. This is thought to be the case as non-specialized parts of the organizational structure might make decisions on which they have little understanding. This little understanding can lead to mistakes or non-consensus, as larger groups of people have to agree on a decision than in a simple structure or machine bureaucracy. In relation to this is it expected that signs of a simple structure will have similar effects on crisis induced learning as that of the machine bureaucracy. This is thought as the simple structure has a clear organizational division. This clear organizational division will probably lead to less mistakes as parts of the system have expertise on the decisions they are taking. Hence, signs of a simple structure will lead to a neutral to negative effect on crisis induced learning as there is simply less to learn from. A full summary of all structures, including the definition, can be found in table 1.
3.3 Media Attention
In addition to the previously mentioned factors, one other factor has been chosen as research Deverell (2009) suggested that it could have an effect on crisis induced learning. The last explanatory factor that was selected is media attention. It is assumed that this explanatory factor has an influence on the amount of crisis induced learning that can be generated after a crisis event. This thesis suggests that negative media attention will lead to more crisis induced learning. Under negative media attention does this thesis view all media information that is blaming the company or emergency organizations for the crisis. Negative media attention can be recognized by its use of words and how these are brought in relation to the companies at which the cases occurred, and to the emergency services that assisted them. It is expected that negative attention will have a positive influence on crisis induced learning. This is expected as this thesis suggests that companies or organizations want to prevent future negative media attention from taking place. By this is meant that organizations will, after negative media attention, focus on how to maintain their image with the public. It is assumed that this image can be maintained by preventing future accidents or crises from taking place. By learning from these events and ultimately preventing them, companies or organizations shield themselves from negative media attention in the future. Thus, by receiving negative media attention are organizations more motivated to learn from past crisis events. If they learn from these situations, further damage to their reputation or brand can be avoided. Learning from their past mistakes can be positive if they want to upkeep the reputation they have built over the years. This thesis hence predicts that negative media attention will lead to increased crisis induced learning. In dimensions this would mean that the Intentional Cluster will lead to more crisis induced learning than the Victim and Accidental Cluster. The previously mentioned clusters will be explained in the section below.
As media attention might be hard to measure on itself, a theory has been chosen in order to simplify this process. While all other explanatory variables rely on a set of dimensions and aspects, a similar system has been selected for media attention. Hence, clusters or dimensions, as explained by Coombs (2007), will be used to evaluate the kind of media attention that occurred in the selected cases. These are required to evaluate whether the media attention can be viewed as negative for the corresponding companies and organizations. The framework that has been selected to measure media attention stems from the Situational Crisis Communication Theory (SCCT). Coombs (2007: 163) explains that a crisis can be viewed as a reputational threat to an organization or authority. A damage to the reputation of a company can affect the way in which stakeholders interact with the organization (Barton, 2001; Dowling, 2002). Coombs and
Holladay (2005) add that post-crisis communication can aid companies and institutions at reducing or preventing reputational loss. Wartick (1992) indicates that reputation can be interpreted as a collective evaluation made by stakeholders about how well an organization is living up to its stakeholders’ expectations. These expectations are based on the past behavior of the organization (Coombs, 2007: 164). Stakeholders receive this information via different channels such as mediated reports, news media, advertising, inspections, and ‘second hand information from other people’ such as web blogs (Coombs, 2007: 164). Most of this information is thus transferred via media (channels). This makes media coverage one of the most important factors for an organization’s reputation management (Carroll, 2004; Carroll and McCombs, 2003; Meijer, 2004). Hence, this study focusses on how media attention can have an influence on crisis induced learning. It can be assumed that the public image of these incidents might have an influence on the (public) reception of these incidents and their progression. Although Coombs’ research does not focus on media attention as a factor, others such as Deverell (2009), Ma et al.
(2005) and Dekker and Hansén (2004) discuss the importance of media attention for a crisis and its learning process. Coombs’ framing method has however been slected to measure media attention in a dimensional way. This method is necessary in order to compare the results of the different explanatory factors.
SCCT divides incidents in three different scales called clusters. The existing clusters can be qualified as the following: (1) The Victim Cluster, (2) The Accidental Cluster, and (3) The Intentional Cluster. The first cluster applies when the crisis was outside of the influence of mankind, such as natural disasters, or when the organization is viewed as the victim of the event (e.g. when employees have tampered with instruments or machines). The second cluster applies when the incident occurred due to an accident, for example a technical failure. In these incidents, organization have little ‘attributions of crisis responsibility’ (Coombs, 2007: 167). The incident is additionally considered an accident, the organization could not prevent the incident from
occurring. The third cluster applies when the organization is responsible for the event and can be blamed for how the incident occurred. Hence, a very strong attribution of crisis responsibility is present. Examples of these incidents are human-error accidents and organizational misdeeds (Coombs, 2007: 167). It is expected that the Intentional Cluster will lead to the most crisis induced learning. This is expected as in the intentional cluster, mistakes will presumably be man-made. Due to the fact that man-made mistakes have been made, one can learn from these
mistakes and write about them in artefacts. Because these mistakes will be mentioned in the artefacts, the intentional cluster will likely lead to the highest amount of crisis induced learning. The intentional cluster can also be viewed as the cluster in which presumably the most media attention is amassed. The intentional cluster has been selected as such as intentional crises will often lead to more reports and information, as there is more to discuss. This will consecutively
lead to more (negative) media attention, explaining why the intentional cluster has been selected as the cluster with the highest level of (negative) media attention. In relation to this is it also expected that the victim cluster will lead to the least amount of media attention as media can merely report on the situation itself. In the accidental cluster, more media attention might be generated than in the previous one. This amount of media attention will however not measure up to the amount of media attention generated in the intentional cluster. A moderate amount of media attention has been assigned to the second cluster as this one likely does not generate as much “sensation” as the third cluster. A small accident because of a system failure is not as nearly as sensational as a company ignoring safety regulations. This explains the attribution of media attention to the corresponding clusters. In the analysis will the Chemie-Pack and the Chemelot case be analyzed according to the previously mentioned clusters and their indicators. The cases will then, after the reports haven been analyzed, be assigned to their corresponding clusters.
A complete summary of the media attention factor and its dimensions can be found in table 1.
4. Methodology 4.1 The design of the study
The design of this study is that of a case study. As explained by Bennett (2005: 5) a case study approach can be explained as: “the detailed examination of an aspect of a historical episode to develop or test historical explanations that may be generalizable to other events”. This thesis will hence test two historical events to see whether factors can be generalized between the two
selected cases. Another reason why specifically a case study has been chosen for this thesis is that case studies can be strong on points where statistical methods tend to fail (Bennett, 2005:
19). As learning is difficult to quantify, case studies could aid in measuring crisis induced learning. The use of case studies for this thesis can prove to be beneficial, as case studies give researchers the opportunity to study causal mechanisms of individual cases in great detail (Bennett, 2005: 21). Because this study wants to research whether certain explanatory factors have an influence on organizational learning, case studies are the best possible research design to provide an answer to this question.
4.2 Case Selection
The cases that have been selected for this study are based on the statement by Broekema (2018; 16) that even though public organizations often do not show much organizational learning after a crisis, there are events in which the organization does learn after a similar event has taken place. In his piece, Broekema explains that a similar attitude was present in the Dutch Food Safety Services (NVWA) after the swine fever outbreak in the Netherlands in 1997. After the outbreak of the disease, the Dutch Food Safety Services showed that new insights had been gained from the situation, as the crisis protocol was reviewed, a crisis archiving system was put in place and the foundations were placed for an internal crisis management division (Broekema, 2018; 16). This thesis will build upon a similar theory, as it wants to investigate whether different levels of crisis induced learning have occurred in the Chemie-Pack and Chemelot case and if this
difference could be explained by comparing the two cases. Furthermore, have the Chemie-Pack and Chemelot case been specifically selected out of several crisis related incidents that took place in the Netherlands in the past few years. The reason why these cases are deemed as special is because they both included chemical fire incidents that received large amounts of media attention. Additionally, did both fires have an impact on surrounding areas and were there
questions of possible health consequences for the environment and nearby population (Onderzoeksraad voor Veiligheid, 2012; Trepels, 2018). Furthermore, did both fires obstruct nearby activity as pupils were kept in school and roads were closed (Onderzoeksraad voor veiligheid, 2012: 6; Trepels, 2018). Another reason why both the Chemie-Pack and Chemelot cases are often linked is that in both cases had existing issues regarding safety measures and inspections. In both cases did inspections point out that operational instructions were ignored and that possible risk scenarios did not receive the necessary amount of attention (Onderzoeksraad voor Veiligheid, 2012: 7-8; Trepels & Hubers, 2018). Moreover, are these cases very similar as both of the incidents occurred after employees were working with parts of the industrial
machines (Onderzoeksraad voor Veiligheid, 2012: 9; Trepels & Hubers, 2018). A last reason that inspired the selection of these specific cases is that after the Chemie-Pack (and Shell fire), concerns were raised for a possible similar situation at the Chemelot park (L1, 2014). As both cases have multiple points in common, they have been deemed comparable and suitable for a case study design. It should however be noted that the cases are not completely similar, as this is almost impossible to achieve for a case study design. A case study design with identical cases cannot be created, resulting in the selection of the previously mentioned cases. These validity related problems will be discussed in the last part of this chapter.
As both cases have been very impactful and similar, it would be noteworthy to understand what sets them apart. A hypothesis for this thesis is that different levels of crisis induced learning have occurred in both cases. It is expected that the levels of crisis induced learning will have been higher in the Chemie-Pack case than in the Chemelot case. This is assumed as the explanatory variables are expected to have had different effects on both cases. In short, this thesis wants to
understand if there has been a difference in the level of crisis induced learning between the Chemie-Pack and the Chemelot case and how this was caused.
4.3 Data Collection, Analysis and Measurement
The data for this study has been obtained through various channels. Firstly, most reports on the Chemie-Pack case have been obtained via a link on the website of the Dutch fire fighting forces. On this webpage were several reports collected that discussed the Chemie-Pack fire in great detail. Secondly, remaining reports on the Chemie-Pack case and all reports on the Chemelot case have been gathered on the internet. This has been done by typing in report, with the corresponding case in the search bar. The reports that were selected for this study were all conducted by independent organizations and have been checked for their validity. Small scale reports by locals or individuals have been left out, as these could not be traced or verified based on their information. Hence, only reports constructed by larger investigative companies have been used. A full list of all the reports that have been used in this study can be found in table 5. Data gathering for this thesis took place by searching for the previously mentioned explanatory factors in the selected reports. Words that could be associated with the explanatory factors were entered in a search bar. The reports were then checked for hits with the corresponding words. Moreover, were hits checked with their context to verify whether the information would be useful. This was necessary to establish whether the corresponding word would speak of the explanatory factor in the right context. The words that the reports were scanned for were: leiderschap, (social) media, organisatie, structuur, veiligheidsregio, commandant, brandweer, brigade, onderzoek, rapportage, bestuur, burgemeester, management, manager, afdeling, krant, tv, internet.
Words that corresponded with the right context were then used in the analysis of this thesis. Information that was found within these parts of text was then used to investigate the explanatory factors and their corresponding dimensions and aspects. The data that was found using this technique was then analyzed according to the previously explained dimensions and aspects. The dimensions had to be added to this research as to measure the different explanatory factors. If a case would show multiple signs of a certain dimension, it would be assigned to the
corresponding one. When not enough signs would be found to allocate a case to a certain dimension, the results would remain inconclusive. This would also be possible if a case showed multiple signs of two different dimensions. After finding the three explanatory factors in both cases and having assigned them to the right dimensions, the results could be interpreted.
4.4 Limitations of the Study
4.4.1 Validity and Reliability
Even though this thesis aims to be conducted with the highest possible validity, some concerns need to be addressed. Firstly, various reports used in this study have been found on a website owned by the safety regions. This could mean that a number of the reports used in this study could have been biased. Documents present on websites of the safety regions could have been biased, as they might have selected reports that do not criticize their approach. Secondly, the number of reports analyzed in this thesis cannot be seen as an actual representation of all available reports on both cases. Due to time constraints, several official reports had to be selected. This would mean that other information might have been excluded from this thesis. Therefore, different conclusions might have been drawn if all available information had been included in this research. Thirdly, as this thesis is built on a case study, it should be noted that no
two cases are completely similar. Even though this thesis tries to compare two cases that seem very similar, differences between the two cases are inevitable. Fourthly, this study is of a
qualitative nature and is hence restricted in some parts. The fact that this study is of a qualitative nature means that the aim of this research is to find out why or how a certain phenomenon came to be. In order to do this, the researcher needs to immerse themselves into the situation they want to study. This means that the results of the study can be biased as it relies on the view of the observer. Due to this personal view is it difficult to reproduce the study under the exact same circumstances. Hence, one should be careful with generalizing the findings of this study to other situations and circumstances. Fifthly, in relation to the previous argument, the use of different variables might change the outcome of this study. As variables are personally selected by the researcher, they might be different from variables used by other researchers. In other words, the same study can be done, but with different variables. If this were to happen, completely different outcomes could be possible. Lastly, as this thesis is to be conducted within a certain time frame, there could be a problem concerning the time limit. Qualitative studies are usually conducted over a longer time frame in order to gain the best understanding of the subject of the study. As this thesis has to be handed in during the summer of 2019, only a limited timeframe remains to research the subject. This means that the researcher might have missed certain aspects of the theory or analysis as a time limit was present. In addition to this could the smaller timeframe have meant that the researcher was unable to utilize all available research on the cases. While problems have been acknowledged, other points of this study have had a positive
influence on validity. One of these points is that the research design and the use of theory in this study has been heavily based on previous research and findings on crisis induced learning. Theoretical orientation has aided this thesis in creating a structure that could prove the existence
of crisis induced learning. It should additionally be noted that as the notion of learning remains vague, quantitative research would have been difficult to carry out. As learning is hard to quantify, a quantitative design might not have been able to indicate the existence of crisis induced learning. Because learning depends on culture, time and context, qualitative measuring systems have been deemed as the best way to assess the presence of crisis induced learning. Another way to ensure that internal validity is present is by comparing the results of both cases. Comparing the results on the presence of crisis induced learning should aid the study in
discovering whether the data are valid and usable. Due to the time constraint however, two cases have been chosen instead of multiple ones. Multiple cases have not been used in this study as this would be too time consuming. The use of more cases would have furthermore meant that the cases would be studied less in depth. A case study with two specific cases was chosen as the two cases could be compared in depth within a specific timeframe. This does enhance one part of the external validity, as the scope of the phenomenon is narrowed. The inclusion of more cases could bear the risk of overgeneralization or could possibly create a scenario in which incomparable cases are used to generate a high amount of external validity.
5. The Cases and their Backgrounds
While both the Chemie-Pack and the Chemelot case concern chemical site related incidents that have taken place in the past few years, differences between the two need to be established. The following section will hence highlight the two separate cases. Additionally, will this part of the thesis focus on the origins of the cases. This information will be used in order to get an overview of the different cases and their commonalities. Starting in chronological order, the first case that
will be discussed is the Chemie-Pack case, often also named the Moerdijk Fire. The second case that will be discussed is a small summary of the Chemelot incidents in 2016.
5.1 Case 1: The Chemie-Pack Fire
On the fifth of January 2011 at 14:30, a fire broke out at Chemie-Pack during pump maintenance (Onderzoeksraad voor Veiligheid, 2012: 6). Due to the cold weather conditions, the pump’s muffler would freeze. This would cause delay and problems for employees as they could simply not continue their tasks. This problem however occurred more often and hence, employees were used to utilizing a gas burner to de-ice the pump’s muffler (Onderzoeksraad voor Veiligheid, 2012: 9). The use of this instrument on the muffler was nonetheless against Chemie-Pack’s rules and permit. Furthermore, did the environmental license specifically list the instances in which open fire was allowed and forbidden. The use of a gas burner on this part of the pump was extremely dangerous as the easily flammable fluid xylene was stored in the drip tray of the pump. The muffler was heated twice and the second time the xylene caught fire. The employee who was working with the burner and the pump noticed the fire and left in order to extinguish the flames with a fire extinguisher (Onderzoeksraad voor Veiligheid, 2012: 9). While doing so, the employee did not press the pump’s emergency stop, nor did he or she turn off the pump’s loader. Because the pump’s loader had not been stopped, chemical materials would continue to flow from the pump. This would cause problems later on, as burning resin would steadily flow from the machine. While the employee was not actively trying to extinguish the fire, he or she did try to notify others of the fire. Another employee however noticed the fire and reported this via the intercom to the reception. Furthermore, did this employee attempt to extinguish the fire by using a small extinguisher (Onderzoeksraad voor Veiligheid, 2012: 9).
With the reception aware of the fire, the manager, the in-house emergency personnel and the fire brigade were notified of the incident.
The first extinguish attempt by one of the employees remained ineffective due to the use of a powder extinguisher. Other attempts failed due to the constant flow of burning resin.
Additionally, had one employee attempted to extinguish the fire by using a strong spurt of water (Onderzoeksraad voor Veiligheid, 2012: 9). The use of this did however have the opposite effect as the burning xylene and resin were moved. Due to this, the fire could expand further than before. The pressure on the pump’s pipes caused the pipes to break. Hence, even more resin was released which immediately caught fire because of the already burning xylene. As the fire progressed, nearby synthetic containers were immensely heated as a result of the fire. The burning resin was so incredibly hot that the outer walls of the synthetic containers melted within one minute (Onderzoeksraad voor Veiligheid, 2012: 9). Because the outer parts of the synthetic containers had melted, the chemical content within also caught fire. Thus, the fire could expand, resulting in an even larger puddle fire (Onderzoeksraad voor Veiligheid, 2012: 9-10).
British research on the use of IBC’s (a certain type of synthetic containers similar to the ones used at Chemie-Pack) concluded that the containers are well equipped to handle chemical materials but are unable to stand high temperatures (Onderzoeksraad voor Veilighheid, 2012: 10). Tests during the research pointed out that the containers would deform above 70 degrees Celsius and would melt between 105 to 130 degrees Celsius (Onderzoeksraad voor Veiligheid, 2012: 10). The report by the Onderzoeksraad voor Veiligheid (2012: 10) found that managers and employees of Chemie-Pack were only able to provide a small and insufficient amount of risk management. They concluded this according to the following three statements. Firstly, the company and its employees had performed prohibited actions by placing hazardous chemicals at
the inner part of Chemie-Pack’s terrain. The placement of these containers at the inner part of the company was of great importance, as the presence of the containers attributed to the growth of the fire. Another hazard that contributed to the incident one was the use of open fire on the inner terrain, and the fact that the pump’s emergency stop had not been activated. If gas burner would not have been used on the pump in the inner terrain, the fire would probably not have occurred. Lastly, the deactivation of the machine and the pump could have prevented the intensity of the fire, and possibly, the continuation of the fire to the nearby synthetic containers.
5.2 Case 2: The Chemelot Incidents
On the second of February 2016, 6.000 kilograms of flammable gas, mostly consisting out of methane. The gas was released or a period of about 21 hours. The cause of the incident was an operating error in the hydranon-2 factory. Within the factory, gasses are created for variating purposes. One of these cases is “spuigas” which is usually directed from the factory towards the “Centraal Stookgasnet”3. If the created gasses do not withstand the quality control for “spuigas”,
they are released to the outside. The disposal of these gases occurs at a height of 15 meters, which is considered a safe height for its disposal. This plan is usually put in motion if the faulty gasses mainly consist out of nitrogen (Onderzoeksraad voor Veiligheid, 2018: 44). The emission of “spuigas” to the outside occurred when, after a factory stop, work was resumed. Due to this stop, the “spuigas” was released to the outside instead of the “Centraal Stookgasnet”
(Onderzoeksraad voor Veiligheid, 2018: 44). During the restart of the factory, the direction of the “spuigas” remained to the outside. Instead, the gas should have been directed to the central gas
heating network. The emission was cut off when an employee of a nearby company smelled cyclohexanone (Onderzoeksraad voor Veiligheid, 2018: 44).
On the 18th of February 2016, about 33.400 kilograms of flammable isobutane was released from
the low-pressure-polyethylene factory 3 at SABIC (Onderzoeksraad voor Veiligheid, 2018: 44). This was the result of an internal leakage in a heat exchange unit. Due to this, the isobutane was moved together with the cooling-water cooling tower. Henceforth, the isobutane was released to the atmosphere (Onderzoeksraad voor Veiligheid, 2018: 44). Insufficient flow and quality of the cooling water resulted in corrosion in cooling element. This corrosion finally resulted in the leakage which led to the incident. The detection system that should have warned of a possible leakage was out of order. A portable explosion meter was utilized as a backup option but this option was not comparable to the original. The emission was finally discovered when employees noticed that the use of isobutane was higher than normal (Onderzoeksraad voor Veiligheid, 2018: 44).
On the 22nd of February, 2016, 8.700 kilograms of flammable ethylene was released to the
outside. The incident occurred at the primary compressor of the high-pressure-polyethene factory. The gas was released for a time period of about 10 hours (Onderzoeksraad voor
Veiligheid, 2018: 44). It is necessary that during the startup of the compressor, the last remains of the ethene are let off at a safe location4 by shortly opening two hand stop valves. If this occurs,
only a small and allowed amount of ethene is released to the outside. The faulty emission however occurred when, after the startup procedure, the operator forgot to close the two hand stop valves. The colleague that replaced him/her in the next shift assumed that all correct steps
