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Learning from Match Day Disasters:
Organisational Learning and Developments to Safety
within the UK Football Industry
Samuel Mark Stocks
Student Number: s1850415
Crisis and Security Management Msc Thesis
Thesis Supervisor: Dr. Yannick Veilleux-Lepage
Second Reader: Dr. Marieke Liem
Date: 07-06-2020
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Table of Contents
Chapter 1- Introduction 3
Definition of Concepts 7
Layout 8
Chapter 2- Theories of Organisational Learning 11
Learning on the Organisational Level 11
Organisational Learning Following Crisis Events 13
Long-Term Organisational Learning 15
Differing Degrees of Organisational Learning 16
Chapter 3 - Methods 20
Methodological Approach 20
Method of Analysis 20
Facilitating Aspects to Analysis 23
Data 25
Chapter 4 - The Disasters and The Development of Safety Policy and Regulation 26
Prior to the Disasters 26
Issues of the Existing System and the Disasters 28
The Valley Parade Disaster 28
The Hillsborough Disaster 30
Resulting Policy Changes 31
The 1987 Fire and Safety of Places of Sports Act 31
The Football Spectators Act 1989 33
The Safety Advisory Groups 36
Chapter 5 –Changing the Appearance of Football 39
The Physical Development of Safety in Stadiums 39
Chapter 6 - Long Term Functioning of the Industry 44
The Production of Guidance 44
Researching and Mitigating Emerging Risks 51
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Chapter 1- Introduction
The 1980s witnessed two of the worst football-related disasters of the entire spectator history of the sport.1 The first of these was the Valley Parade disaster which occurred on the 11th May 1985, during a 3rd division match between Bradford City and Lincoln City.2 In the 40th minute, attention was drawn to a small fire that had broken out in the main stand.3 Due to windy conditions, the fire quickly engulfed the whole wooden structure of the stand, trapping many supporters in their seats.4 Some match-goers managed to escape the blaze by running onto the pitch, yet those who tried to use the rear exit found themselves trapped in the turnstile area, as standard procedure at some grounds was to keep these gates locked during matches.5 Fifty-six supporters died that day with 265 suffering non-fatal injuries.6 Four years later, saw the British football industry scarred once again with yet another catastrophe. The Hillsborough disaster of 1989, saw 96 Liverpool fans crushed to death and over 700 injured during the F.A cup semi-final between Liverpool and Nottingham Forest.7 This happened as a result of poor stadium design, regulation and maintenance as well as failures on behalf of the South Yorkshire Police organisational process.8 The design of the Leppings Lane stand consisted of high latitudinal fences at the front of the pitch with 6 longitudinal fences splitting the stand into a pen structure.9 Operational pressures on the Police force in charge of filtering fans into the stand, led to the opening of exit gate C.10 This meant that an abnormally large number of supporters flooded into the stand, consequentially causing overcrowding in the central pens of 3 and 4 situated behind the goal.11 This overcrowding caused supporters to be crushed under the weight of the crowd within this confined area. These disasters were subsequently followed by serious inquests not only into the direct causes of the incidents but also into the underlying organisational and regulatory structures within the U.K football industry.
These fundamental re-assessments of the functioning behaviour of the Football Association and the Sports Ground Safety Authority following these incidents can be
1 The thesis uses the term ‘football’ over ‘soccer’ due to this being the most commonly used reference to the
sport within the United Kingdom.
2 Sivaloganathan, S., and M. A Green. "The Bradford Fire Disaster." Medicine, Science and the Law 29, no. 4
(1989), 279.
3 Ibid. 4 Ibid. 5 Ibid, 285. 6 Ibid,279.
7 Hillsborough: the Report of the Hillsborough Independent Panel. London: The Stationery Office, 2012, 27. 8 Ibid,3.
9 Ibid. 10 Ibid,8. 11 Ibid.
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considered as the key turning point in the conception of and behaviours towards safety within the UK football industry. Central to this thesis comes the concept of organisational learning, which is concerned with how an organisation updates and continuously learns from previous lessons and events in order to provide the highest level of disaster prevention and safety maintenance possible.12 The focus within the research presented in this paper is concerned with showing how the organisations responsible for safety policy, primarily the Sports Ground Safety Authority (SGSA), not only learned from the previous disasters but also how these lessons can be recognized within how the industry has approached new challenges to safety over the last 30 years. Thus, the thesis statement argues that the overall process of safety and resilience policy development within the UK football industry since the disasters, exhibits a high degree of organisational learning to that of a full cultural readjustment within the functioning of the industry.
The research question at the heart of the thesis is: How and to what degree is organisational learning exhibited within the UK football industry’s attempts to improve safety and organisational resilience following the disasters of the 1980s? Using a process tracing approach, the thesis analyses the behaviour and policy actions of the UK football industry towards safety and resilience over the last 30 years. This is in order to identify the degree to which the theory of organisational learning occurred within its role as a causal mechanism behind these changes. The thesis analyses the level of success within the applicability of this theory as a causal mechanism within each significant development since the disasters, of which allows the thesis to determine the overall extent to which the industry has not only learned from the disasters of the 1980s but continues to do so within resilience practices.
To study the development in attitudes towards safety policy and regulation the paper will follow the methodological approach of process tracing. This method focuses on the examination of historical evidence, so as to identify the overarching processes and mechanisms, in this case organisational learning, driving the sequence of intervening variables and events, this being developments regarding safety.13 The focal point of this method is about identifying the intervening causal process and mechanism between independent variables which led to the dependant variable of the outcome.14 In context, the thesis will inspect evidence of changes within approaches, regulation and policy towards safety within the UK football industry. This
12 Argote, Linda. Organizational Learning. Springer Science & Business Media, 2012, 31.
13 Bennett, Andrew, and Jeffrey T. Checkel. “Process Tracing.” Chapter. In Process Tracing: From Metaphor to
Analytic Tool, Strategies for Social Inquiry. Cambridge: Cambridge University Press, 2014, 6.
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is to understand whether the theory of organisational learning can be considered as a causal mechanism in the process leading to the outcome of improved safety within football stadiums in the UK. Using this method therefore allows the thesis to reflect on how and the degree to which a process of learning has taken place within the industry.
The academic relevance may firstly be found through the way in which the thesis adds to the broader field of research on the subject of learning from disasters within crisis management. The vast amount of research within this field of study will be highlighted in depth within the theories of organisational learning section. However, the primary academic relevance of this thesis may be found on the basis of the limited research within academia on this particular topic of learning within the development of safety at football matches within the UK. The only other similar writings on this subject were compiled by Dominic Elliot and Denis Smith, in their investigation on whether cultural readjustments had taken place following four main disasters of the 20th century.15 In their assessments they analyse how the football industry reacted to these four disasters in an attempt to distinguish whether a process of cultural re-adjustment may be recognized within the industry.16 Ultimately, their research found that a full cultural readjustment did not take place meaning the organisational learning process could have gone further and that areas of the industry still remained vulnerable to crisis.17
Since the publication of Elliot and Smith’s study in 2006, numerous identifiable developments within regulatory behaviour of the SGSA and the Football Association have taken place. One example of this would be the way in which these organisations have improved transparency through increasing the level of public availability of information with regards to their policy goals and approaches to certain issues. A notable driver here is the development in how the internet has changed the way information is shared since 2006. Particularly within the last decade, the FA and SGSA have been able to post research and explanations behind their implemented policies on their websites. This highlights an increase in the level of transparency in this particular policy area as the reasoning and documentation of the specific decrees are available for all to read. Thus, this thesis will be able to build on the previous research by not only being able to analyse the new organisational processes and developments over the last 14 years regarding new safety policy, but by also understanding the research and reasoning provided for certain policy approaches. This is made possible through the development in the
15 Elliott, Dominic, and Denis Smith. "Cultural Readjustment After Crisis: Regulation and Learning from Crisis
Within the UK Soccer Industry." Journal of Management Studies 43, no. 2 ,(2006), 290.
16 Ibid. 17 Ibid, 312.
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availability and accessibility of information regarding such policies, a level of transparency that was not present at the time of Smith and Elliot’s research. The increased level of access to information, thus enables the current thesis to contribute differing outcomes with regards to this research topic.
Furthermore, this thesis seeks to find relevance in researching the concept of organisational learning through focusing on determining the degree to which the theory may be considered as a causal mechanism. Smith and Elliot primarily focus their research efforts on determining whether a full cultural readjustment took place within the industry since the highlighted disasters.18 The analysis sections will also attempt to carry out a similar method of observation in analysing the degree of learning. Hence, the increase in the amount of observable change within the industry towards safety since their publication, provides the thesis with an opportunity to add to their original conclusions that the industry had failed to exhibit a full cultural readjustment. Further to this the study will seek to understand the degree to which organisational learning can be seen as a driver behind the developments in safety policy, consequentially adding to academic relevance in this particular topic of study. The increase in available data in the research approach compared to Smith and Elliot’s work naturally creates the opportunity for contributing differing conclusions.
The societal relevance of the thesis may be highlighted primarily through the fact that within the UK, football is the most popular spectator sport. In 2019, the average match attendance of Premier League games stood at 38, 181 supporters.19 These large average attendance figures also apply within the lower leagues of English football, the Championship (English second division) had an average attendance of 20,172 in 2019, League One (English third division) 8,724.20 The same applies for the Scottish leagues with the Scottish Premier League amassing an average attendance of 15,990 for 2019.21 These figures outline the large magnitude of supporters attending games within the UK every week. Furthermore, the popularity of British football outside of the UK has also grown tremendously attracting supporters and tourists from all over the world just to attend games.22Thus, safety at these games is of vital importance to the brand of British football. The origins of the game, league structure
18 Ibid, 312.
19 ‘EFS Attendances’, european-football-statistics.co.uk/attn.htm. 20 Ibid.
21 Ibid.
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and various other practices relating to football were all founded within the UK.23 Since the UK industry has undergone such a large amount of development regarding approaches to spectator safety since the disasters, the worldwide growth in the popularity of the sport as a spectator event means that the UK must set an example of best practice for other nations, based on the experiences gained in the process of developing safety within the UK industry. This is particularly relevant for developing nations where football is growing into a mass spectator sport such as India and Indonesia.24 It is imperative that developing nations are able to learn from previous disasters, so that other nations can also learn from and avoid such incidents. Therefore, by investigating the learning processes of the industry, the paper may be able to provide valuable recommendations regarding the best practice for the provision of safety at such events.
Within the growth in popularity of attending football matches also comes new supporter demands with regards to desired match day experiences. Analysing the approaches of the FA and the SGSA towards these new supporter demands provides the thesis with both academic and societal relevance, as they bring to light cases where these organisations must utilise and apply previous lessons from disasters of the past within approaching new dilemmas within the industry. Such examples the thesis will inspect how the industry has approached the demands for the re-instating of supporter standing areas in stadiums, something which was banned following the Hillsborough disaster.25 Hence, examining the UK industry’s approach to such developments, should be able to shed light on the extent of learning from previous disasters within the industry’s stances on these developments. This thesis will therefore provide academic relevance through the emergence of new evidence and cases to study alongside the concept of organisational learning, as well as societal relevance within understanding how an industry can draw on previous disasters in approaching new developments.
Definition of Concepts
The main content of analysis within the thesis concerns changes and developments made within the industry towards the safety and organisational resilience practices specifically relating to safety within football stadiums in the UK. The concept of safety within the field of risk
23 Walton, John. "The Origins of Working-Class Spectator Sport: Lancashire, England, 1870-1914." Historia Y
Comunicacion Social 17, (2012), 126.
24 Wigmore, Tim. ‘Football’s New Frontiers: Why India and China Could Be the next Global Superpowers’. The
Telegraph, 10 June 2018. telegraph.co.uk/football/2018/06/10/footballs-new-frontiers-india-china-could-next-global-superpowers/.
25 ‘Wolves Become First Premier League Club to Install Rail Seats at Current Home’. TalkSPORT, 28 January
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management can thus be understood as the provision of protection from or the prevention of a certain danger or risk that may otherwise cause harm.26 Therefore, the thesis recognises the concept of safety within the UK football industry to be policy measures taken by the mentioned authorities, aimed at addressing the avoidance of dangers or risks that may cause harm within stadiums.
The concept of organisational resilience, refers to an organisation’s ability to learn from previous crisis events as well as to self-regulate based on the implementation, reviewing and updating of internal norms and practices. 27 This concept captures an organisation’s ability to self-regulate and provide a strong response to weak signals of potential future dangers and risks.28 This means that an organisation’s resilience depends on how it updates its policy and practices without the recent occurrence of a major incident or event. Of course, the organisation must draw upon previous lessons, but must also be competent in interpreting weak or less prominent indicators of potential future dangers and risks.
The focus on these concepts is to ultimately judge how well the industry has exhibited a process of organisational learning in these areas. For clarity, the thesis understands this concept of organisational learning as the manner in which an organisation exhibits a process of learning through the formation, updating and adaptation of norms and practices based on reflections made regarding previous lessons and events.29 Within the context of the UK football industry this learning process is carried out with the end goal of providing sufficient safety and organisational resilience maintenance.
Layout
The next section, Chapter 2, will discuss the relevant academic literature on the topic of organisational learning, so as to embed the understanding of this theory within the thesis. The section will begin by outlining how the basic understanding of learning can be projected onto the organisational level. Theories of how organisational learning fits into the field of crisis and security management are examined, within this a key focus concerns how organisations recover and learn from disasters. In doing so, the section pays specific attention to how organisational
26 Debray, Bruno, Christian Delvosalle, Cécile Fiévez, Aurore Pipart, Henry Londiche, and Emmanuel Hubert.
“Defining Safety Functions and Safety Barriers from Fault and Event Trees Analysis of Major Industrial Hazards.” Probabilistic Safety Assessment and Management, 2004, 358.
27 McManus, Sonia, et al. “Resilience Management A Framework for Assessing and Improving the Resilience of
Organisations.” Resilient Organisations, 2007, 1.
28 Fabrizio, Bracco, Piccinno Tommaso and Dorigatti Giorgio. “Turning Variability into Emergent Safety: the
Resilience Matrix for Providing Strong Responses to Weak Signals.” (2014), 1.
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learning occurs in different manners. Thus, theories regarding both short-term and long-term learning processes are discussed in respect to the activities and potential processes that can occur within an industry following a disaster event. Through the discussion of each of these theories the section then places the recognisable indicators of such learning processes within the context of the UK football industry, explaining how they may be identified within the analysis. Following this, the theories of how organisational learning can take place to differing degrees is examined. It is here in which the theories of single and double-loop learning as well as the concept of a full cultural re-adjustment following disasters are introduced. Hence, this forms the understanding of the relevant theories which will constitute the basis for the analysis sections to judge how far the learning process went within the actions of the UK football industry following the disasters of the 1980s.
Chapter 3 will explore and explain the chosen methodological approach within the thesis. Importantly, this chapter outlines the process tracing method of analysis, explaining how the theories of organisational learning such as single and double loop learning, are utilized within the analysis of the policy changes made within the industry. In doing this, the chapter underlines how this chosen approach will be applied within each analytical chapter so as to judge the degree of organisational learning. Furthermore, this section also introduces facilitating aspects to analysis, primarily the Process Resilience Analysis Framework which aids the analysis of the developments made regarding organisational resilience. In addition, this chapter also discusses the chosen data sources for use within the analysis, such as the Guide to Safety at Sports Grounds (Green Guide).
Chapter 4, the first analytical chapter, begins by providing a background outline of the football industry’s structure and functioning towards safety prior to the disasters. Doing this allows the chapter to then inspect how the structures and functioning of the industry at this point in time failed to prevent the occurrence of the disasters, allowing specific safety issues within the system to be identified. From this, the initial resulting policy and structural changes are analysed, so as to cover the short-term learning processes of the industry within the analysis. The core argument of this analysis chapter is to show and explain how some areas of short-term policy development in the initial aftermath of the disasters exhibited a high degree of organisational learning, whilst others only displayed a limited degree of learning.
Chapter 5 focuses on the changes made to the physical design and layout of stadiums that occurred as a result of the disasters. Within analysing these developments, the chapter pays specific attention to how successful the industry was in recognising and implementing the
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necessary changes. Thus, this section puts a key emphasis on underlining the impact that the disasters of the 1980s had upon the appearance of grounds in UK. Within this the core argument is made that a clear reflective process took place within the industry regarding the need for new safety policies concerning stadium design, as the industry was able to identify how the disasters were facilitated by this issue. Based on this analysis the section then judges the degree to which organisational learning occurred within the developments made within this particular policy area, the argument is made that these developments together with the structural and functioning changes provide a strong argument for the occurrence a high degree of organisational learning. Chapter 6, analyses the long-term functioning and development of the industry towards safety following the initial changes highlighted in the previous sections. The focal point of analysis within this chapter concerns how guidance practices have developed up until the current day, so as to show the self-reflective nature of the industry within its ability to identify areas of policy and functioning in need of revision and adaptation. Furthermore, this chapter also inspects the researching and mitigating techniques of the industry, in respect to the approaches taken towards the creation of policy towards new and emerging issues to safety within stadiums. In analysing these practices, this section will demonstrate how the long-term research and self-reflective practices characterizing the industry today indicates a strong case of organisational learning that developed from the disasters of the 1980s.
Finally, in chapter 7 the conclusions of the research will be presented, providing a space for a collective judgement to be made regarding the overall degree of organisational learning exhibited within the industry’s attempts to improve safety and organisational resilience. In doing so, this section will thus answer the research question through affirming the thesis statement based on the presented research. Additionally, this chapter will also provide recommendations regarding areas for future academic research on this particular topic.
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Chapter 2- Theories of Organisational Learning
In order to judge the extent to which an organisation exhibits competence in learning through previous events and self-reflective processes, the paper must first explore the current available definitions and conceptualisations within organisational learning. The red thread within this literature review is to forward the argument that learning within organisations takes place on differing levels and extents. Analysing the discussions of these concepts and theories regarding organisational learning in the context of learning from disasters, will allow this section to explain how this theory fits into the study of crisis management. Furthermore, this chapter will utilise the academic theories and concepts regarding organisational learning to understand how all levels within an organisation from the overall organisational functioning down to the individual level, can exhibit various indicators that exemplify that a particular degree and process of learning has taken place. Doing this provides the thesis with identifiable variables, relevant actors and process outcomes that can be highlighted and applied within the analysis and judgement of how far the UK football industry went within the learning process behind the developments made following the disasters.
Learning on the Organisational Level
Establishing a basic understanding of learning, Hale and Freitag, prominent authors in the field of disaster response and safety management within organisations, proclaim that the act of learning at its most elementary level takes place when a deviation from an expected norm, event or goal occurs and is then corrected by adapting ones understanding and practices to address the deviation.30 Levy an influential author in the field of learning theories within the social sciences particularly with regards to policy formation. Understands learning in a similar way to Hale and Freitag, purporting that learning is a change in beliefs or the development of new beliefs, skills or procedures occurring as a result of observation and interpretation of previous experiences.31 With these understandings in mind, it would be fair to assume that from a very primitive level that learning ultimately involves the acquisition of knowledge or skills through either experience or practice.
Focusing on how this understanding of learning has been applied to an organisational setting, Linda Argote, an extremely prominent author within the study of organisational
30Hale, Andrew R., Bernhard Wilpert, and Matthias. Freitag. After the Event: From Accident to Organisational
Learning. 1st ed. Oxford; New York: Pergamon, 1997, 11.
31 Levy, Jack S. "Learning and Foreign Policy: Sweeping a Conceptual Minefield." International Organization
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learning, defines this theory as “a change in the organisation’s knowledge that occurs as a function of experience”.32 Kirwan, an author whom has contributed a great deal of research into the study of effective organisational learning, claims that “organisational learning makes organisations do things differently, or at least think about them differently”.33 These definitions basically highlight how the theory of organisational learning should be considered primarily as a projection of the basic understanding of learning onto an organisational level. This understanding being that organisations have the ability to acquire knowledge and shape practices, routines or regulations through past experiences.
Placed more directly into the study of the UK football industry, a potential identifiable feature of organisational learning would be a case of policy implementation which clearly draws upon the lessons of a previous experience or event. These organisational learning theories allow the thesis to judge the industry’s overall learning competence, through analysing how the SGSA reflects and draws upon previous lessons from the disasters of the 1980s in the procurement of new safety policy.
This projection of a basic understanding of learning onto an organisational level, provides a variety of platforms on which learning must occur in order to identify that learning has indeed taken place within an organisation. De Flers, in explaining mechanisms behind the level of Europeanisation amongst member states of the European Union, utilizes the concept of different platforms of learning, in specifying that the theory of organisational learning includes the institutionalisation of individually learned lessons into routines and procedures of an organisation.34 This application of organisational learning, promotes the idea that this concept is not just a top-down notion and in fact must utilize a somewhat multi-lateral learning perspective within an organisation. This view is supported by Hua and Chan, authors who have together invested a large amount of study into researching innovation and learning culture within organisations. In their writings they claim organisational learning is facilitated through the assimilation of individual insights into the routines of an organisation.35 Organisational learning thus requires event analysis that traces causal factors and determinants of an event on
32 Argote, Linda, and Ella Miron-Spektor. "Organizational Learning: From Experience to Knowledge."
Organization Science 22, no. 5 (2011), 1124.
33 Kirwan, Cyril. Making Sense of Organizational Learning. Routledge, 2016, 50.
34 De Flers, Nicole Alecu, and Patrick Müller. "Dimensions and Mechanisms of the Europeanization of Member
State Foreign Policy: State of the Art and New Research Avenues." Journal of European Integration 34, no. 1 (2012), 28.
35 Hua, Yuanyuan and Chan, Isabelle. Development of a conceptual model for organizational learning culture
and innovation diffusion in construction. Proceedings 29th Annual Association of Researchers in Construction Management Conference, (2013), 408.
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every level of an organisations structure.36 This multi-level learning from experience fits in with McGrath and Argote’s framework for organisational learning, as in this framework, it is claimed that knowledge can be embedded within three elements of an organisation, these being the members, the tools and the tasks.37 Hence, acquiring knowledge from experience can occur within any of these three organisational levels and can therefore have a positive learning effect on the other element’s functioning within the organisation.
To judge the overall extent of learning within the UK football industry, attention must be paid to the multiple levels of actors within the industry. This is because indicators of a learning processes can also concern instances of how more regional actors such as local authority representatives can influence the projection of policy based on more individually learned lessons, into the influencing and implementation of an industry-wide policy. Additionally, this concept of multi-level learning infers that to judge the learning competence of industry as a whole, attention must be also be paid to how actors within the industry adapt to and understand the reasons and lessons behind developments in policy. In a broader sense, this multi-level understanding of organisational learning requires the thesis to pay attention to how sub-organisational and even individual structures within the SGSA understand and influence policy implementation, so as to judge the overall extent of organisational learning within the industry.
Organisational Learning Following Crisis Events
Inspecting how organisational learning relates to the field of crisis and risk management, Elliot and Smith, the only other authors to focus on the case of the UK football industry within this theory, also contributed a fair amount of research to the field of learning within organisations particularly following crises. These authors underline the view that events of crisis provide organisations with the opportunity to consider the unthinkable thinkable, therefore crisis helps in revealing the inadequacies within previous assumptions, norms and practices of an organisation.38 This view clearly fits into the previously discussed basic understandings of learning, in that on the organisational level, the disaster event is simply the previous experience in which lessons can be drawn. From this understanding the importance of crises from a safety organisational perspective is highlighted, as these events should be viewed an integral part of
36 Hale. Et al, After the Event: From Accident to Organisational Learning. 1997, 9.
37 McGrath, Joseph & Argote, Linda. Group Processes in Organizational Contexts. (2008), 608.
38 Smith, Denis, and Dominic Elliott. “Exploring the Barriers to Learning from Crisis: Organizational Learning
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the learning process in identifying areas of practice that had perhaps not been sufficiently addressed.39
Adding to this idea of using crisis events as learning opportunities are the writings of Elena Antonacopoulou, an author who has compiled a large amount of research focused on the functioning and practices within organisations, particularly with regards to the topic of learning. In her writings she puts forward the term ‘organisational crisis’ which fits well within the theory of organisations learning from crisis, as it describes a situation that upsets and challenges an organisations basic assumptions, threatens their survival and creates circumstances in which there is a lack of immediate coping mechanisms consequentially threating organisational legitimacy.40Antonacopoulou uses this concept to highlight how crisis within organisations is an integral and inter-related part of the learning process, as these events highlight technical barriers that are too obscure to predict or comprehend within risk management forecasting.41
Similar to Antonacopoulou’s theorisation of organisational crisis, Christophe Roux-Dufort a key author in relating organisational learning to the field of crisis management, claims that learning from crisis should be integrated into modern organisation’s overall management and regulatory strategies as previous events provide a unique opportunity to learn.42 Adding to this, he declares that previous events of crisis can allow an organisation to improve its organisational competences in reference to crisis management, as organisational learning can prove to be a driving force behind exploiting new knowledge made available from an event.43 This indicates how disaster events can provide valuable information for organisations through forcing a change or re-evaluation in policy via a form of creative tension. Furthermore, Roux-Dufort explains how organisations can develop a culture of safety and crisis preparedness as according to his arguments the largest accelerator for the development of this is learned from previous cases of crisis.44
The basic understanding of organisational learning within crisis management may be viewed as how an organisation learns, reacts and adapts their policies towards crisis prevention
39 Antonacopoulou, Elena P, and Zachary Sheaffer. "Learning in Crisis: Rethinking the Relationship Between
Organizational Learning and Crisis Management." Journal of Management Inquiry 23, no. 1 (2014), 7.
40 Ibid. 41 Ibid.
42 Roux-Dufort, Christophe, and Emmanuel Metais. "Building Core Competencies in Crisis Management
Through Organizational Learning: The Case of the French Nuclear Power Producer." Technological Forecasting & Social Change 60, no. 2 (1999), 115.
43 Ibid, 117. 44 Ibid.
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following a particular event. Ultimately, from an organisational perspective a crisis event should be viewed as an opportunity to improve practice, through the highlighting of failures within the safety system. The scholarly arguments presented suggest that an essential element within in identifying a learning process within an organisation’s actions following a crisis, would be a visible indication of a clear reflection and addressing on an area of practice or policy that facilitated the event.
Identifiable features of this conception would be visible in the more imminent reaction and policy implementation following the disasters of the 1980s. Thus, a competent response from the industry would involve indicators that highlight that organisations such as the SGSA, recognized what went wrong and how previous assumptions and policies failed to prevent the occurrence of the disaster. Further proficiency of the organisations would be shown through the approaches towards addressing and amending the failed policies, indicating that the industry then utilizes the event as a learning step in developing safety policy based on previous events. Additional identifiable features of this concept may also be seen much later down the line than the imminent reaction to crisis events in regard to the development and implementation of policies. One hypothetical identifiable feature would be how the industry continues to utilize the lessons learned within the process of policy formation from previous events within the approaches to updating and creation of new policies. However, the industry’s ability to do this depends on how well the organisations understand the issues with the previous assumptions of which were highlighted by the original event.
Long-Term Organisational Learning
Equally as important as the initial learning processes gained from crisis events are the long-term learning processes that must upheld so as to avoid future disasters. Roux-Dufort promotes the idea that organisations must build up competences that can be used to manage crisis systems in the long-term.45 According to Roux-Dufort, proficiency within long-term learning should be pursued by emplacing proper internal systems for the regulation of prevention, preparatory and reactionary measures to dealing with uncertainties.46 From this understanding, organisational learning is not only a learning from events based phenomena, it can also be exhibited through practice and self-regulation within an organisation. Antonacopoulou supports this in claiming that organisations and leaders must continuously probe and test their organisational norms and
45 Roux-Dufort, and Emmanuel. "Building Core Competencies in Crisis Management Through Organizational
Learning: The Case of the French Nuclear Power Producer." (1999), 122.
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practices.47 In doing this they are more likely to encounter inefficiencies within that particular practice, thus creating more opportunities for organisational learning by ensuing the build-up of crisis resilient norms through repeated self-reflection.48 This means that organisational learning does not only occur following a crisis event, but can also take place through how an organisations continuously reflects upon its the practices and attempts to improve resilience internally.
These theories relating to the long-term learning process of an organisation, like the initial reaction to crisis theories, are vital to assessing the extent of reflection on previous disasters within the organisational learning process of the UK football industry. Inspecting the identifiable features of self-regulation and resilience within the SGSA regarding safety policy, allows the thesis to judge the industry’s ability to spot flaws within its own policy without having to rely on certain events or near misses to trigger safety policy adaptation. Understanding how the industry tests and learns from self-reflection in implementing safety practices, accompanied with the manner in which the industry learns from previous events, provides the thesis with a grounding to assess the overall extent to which the previous disasters are reflected upon within the process of organisational learning.
Differing Degrees of Organisational Learning
Organisations can utilize and learn from crisis situations, highlighted in both the short and long-term reactions to disasters. However, organisations may also be drawn into making common errors following a crisis situation, as human error is intimately intertwined within crisis situations and can often play a role in the learning stages that follow. 49 Whether this be in the form of technical barriers in understanding that are too difficult to comprehend when a crisis occurs.50 Or in the form of negative, passive or naïve attitudes within an organisation that consequentially stunt the learning process.51 External pressures can also misguide actions following a crisis event, an example of this would be public demand for rapid change in the initial aftermath of a disaster. This type of pressure can cause an organisation to rush into changing a procedure or norm without a proper analysis of the processes which led to the incident. Rushed adjustment of policy has the potential to firstly cause something to become
47 Antonacopoulou and Shaeffer. Learning in Crisis: Rethinking the Relationship Between Organizational
Learning and Crisis Management, (2014), 9.
48 Ibid.
49 Antonacopoulou and Shaeffer. Learning in Crisis: Rethinking the Relationship Between Organizational
Learning and Crisis Management, (2014), 11.
50 Ibid, 7. 51 Ibid, 9.
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unsafe due to hastily made changes.52 Secondly, making changes straight away can allow other indicated dangers to go unnoticed, hence passing up an opportunity for the full utilisation of the incident in respect to furthering organisational learning.53 Connected to the research topic, these pitfalls and external pressures that effect an organisation’s ability to learn, stand as potential identifiable features that may have affected the extent of organisational learning within the UK football industry.
The pitfalls of learning from crisis, highlight that certain factors can affect the way an organisation learns from a disaster event, this ultimately means that the extent of learning within an organisation can be examined based on the actions of an organisation following the occurrence of an incident. One of the more prominent concepts mentioned in the academic literature on this topic is the idea of single and double loop learning, also referred to as ‘thick and thin’ learning. Single loop may be understood as learning that seeks to deal with factors at the level of regulations, structures and plans.54 Second loop unlike single-loop learning challenges the core organizational paradigm providing a basis for a full cultural re-adjustment following a crisis.55
This concept of a full cultural readjustment was put forward by Turner in his significant writings on the failure of foresight within crisis organisations. In this particular article he refers to six stages associated with an organisations failure to foresee a crisis.56 The relevant stages to this context being stages 5 and 6, as these stages concern the actions of an organisation following a disaster event. Stage 5 relates to rescue and salvage, this being the first stage adjustment in the immediate aftermath of a crisis, where an organisation will make immediate changes which permit the work of rescue and salvage operations to take place.57 This stage resembles a level of learning similar to single loop learning, as the organisation can be seen to address and react to the initial issue causing the disaster. Following this in stage 6, Turner suggests that a full cultural readjustment should take place where an assessment of institutional beliefs and norms is carried out so that they may be adjusted to the new found understanding of the potential causes of crisis in this field.58 This stage should be considered as the thick
52 Hale. Et al, After the Event: From Accident to Organisational Learning. 1997, 5. 53 Ibid.
54 Smith and Elliot, Exploring the Barriers to Learning from Crisis: Organizational Learning and Crisis. (2007),
522.
55 Ibid.
56 Turner, Barry A. "The Organizational and Interorganizational Development of Disasters." Administrative
Science Quarterly 21, no. 3 (1976), 381.
57 Ibid, 381. 58 Ibid.
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learning stage, as a more reflective process takes place within the organisation assessing cultural norms and functioning.
However, it should be noted that these stages do not always occur following a crisis as an organisation may opt against re-evaluating their existing safety structures and procedures. This is mentioned by Turner, as the need for a full cultural re-adjustment may not be necessary if a particular crisis was caused through a violation of the already prescribed norms and practices, this is then a failure of compliance rather than a failure of the system.59
In the context of studying the UK football industry, the concept of single loop learning would be seen in how the industry reacted to and adjusted policy regarding the causes of the disasters of the 1980’s, such as addressing issues within the design of stadiums identified as an initial cause of a disaster. Whereas, potential identifiable features of thick learning or a full cultural readjustment would be seen in the manner in which organisations within the industry assessed the fundamental beliefs and norms of the industry towards safety as a whole. Possible indicators of this would be changes in the manner in which safety in stadiums is assessed. Another indicator of this may be seen in the development of structures concerning the continuous regulation of safety within the industry. The basis for a full cultural readjustment thus relies on the industry’s ability to extend the process of improvement within safety beyond fixing just the imminent cause of a particular incident.
Overall, these theories of differing adjustments following crisis incidents underline how organisations may learn from crisis in a partial manner (single-loop and initial adjustment) or in fact go further than this by fully utilizing the experience and lessons provided in a crisis through the conception of how a double loop learning and a full cultural readjustment may be made. These concepts highlight how organisational learning can be seen to occur to differing degrees. Ultimately, combined with the theories surrounding the long term and multi-level learning processes, this section has indicated how organisational learning can be assessed to have occurred on differing levels and extents. These ideas are crucial in judging the degree of learning made within an organisation’s learning process that took place within attempts to improve safety and organisational resilience. As theories allow for the identification of cases where perhaps only the imminent issue was addressed yet no real reflective learning processes took place. Conversely, these theories also allow for the identification of policy adaption accompanied with a reassessment of cultural norms, displayed in how the SGSA approach a
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certain safety issue. Hence, being able to identify these two differing concepts within safety policy formation, provides the thesis with a base to judge just how far the learning process went within specific cases of safety policy formation and implementation.
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Chapter 3 - Methods
Methodological Approach
The research question requires the thesis to describe, interpret and ultimately judge, how and to what degree a process of organisational learning took place based the impact of the disasters of the 1980s. This question demands that the thesis must analyse reflections in regard to how they may be recognized in the improvement of safety and organisational resilience, therefore the thesis chooses to take a qualitative approach to research. The main reason for this being that the data needed to analyse the research question demands an in-depth focus and interpretation of the content of policies relating to safety and resilience. Doing this allows the thesis to gain an understanding of how far the disasters are reflected upon within the theory of organisational learning, in regard to the formation process of the individual policies. Hence, repeating and applying this basic method of analysis to numerous examples of polices, ultimately allows the thesis to judge the overall extent to which organisational learning is exhibited in this particular field of policy formation. The key focus in the analysis then is not on gaining quantifiable measurements, but instead on gaining an understanding of how and how far a theoretical concept can be recognised as a mechanism within the phenomenon of policy formation. Hence, the decision to follow a qualitative research approach.
Method of Analysis
The analysis chapters will each focus on mapping out the observable developments within the industry’s approach to one specific regulatory or safety issue. Doing this will allow the thesis to inspect how the policies and practices regarding safety have changed within the industry. In addition, mapping out and analysing changes over the whole time period will allow the thesis to identify how the implementation of certain measures or changes to practice, reflect the implementation of lessons learned from the events of the 1980’s years after the disasters. Consequentially forming a basis to draw conclusions concerning the overall extent of the reflective organisational learning process within these particular fields of development.
Through focusing on the method of process tracing the thesis will attempt to identify organisational learning as a causal mechanisms behind policy change, this is done to answer the ‘how’ of the research question.60 This methodological approach entails identifying the intervening causal processes and mechanism between independent variables leading to the
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dependant variable of the outcome.61 In the case of this thesis the hypothesized causal mechanism behind the outcome of improvements to safety policy is the theory of organisational learning. Inspecting casual mechanisms through the lens of process tracing entails the combination of three different social mechanisms leading to the outcome. The first of these is the situational mechanism, of which refers to the environment in which the organisation operates and defines its objectives and goals.62 In context of the research, this would be the goal of the industry to provide sufficient safety policy. Following this comes the action-formation mechanism, which shows how these objectives and goals influence the actor’s behaviour.63 Such a behaviour would be the reviewing and recognition for the need to develop policies following the occurrence of a negative incident regarding safety. Next comes the transformational mechanism, which concerns how the behaviours of entities within the industry bring about the desired outcome.64 In the case of this study, this would be how the organisations form the policy based on prior knowledge and previous experiences. The latter two of these situational mechanisms being the key focus areas of analysis as they primarily concern the learning and implementation stages within policy adaptation. The figure below, based on Haverland an Blatter’s visualisation of this theory, attempts to explain how organisational learning may fit as a hypothesized causal mechanism for the outcome of improved safety
policy.65
61 Ibid.
62 Hedström, Peter, and Wennberg, Karl. Causal Mechanisms in Organization and Innovation Studies, 2016, 94. 63 Ibid.
64 Ibid.
65 Blatter, Joachim, and M. Haverland. Designing Case Studies: Explanatory Approaches in Small-n Research.
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The first analysis chapter will focus on mapping out and analysing the developments made to the regulatory structures and practices concerning safety since the major disasters. The chapter will first begin by explaining the structures of safety regulation and inspection in place before the disasters and how they failed to prevent the occurrence of the events. From this the analysis will then move onto focusing on the imminent changes made to the structure of the industry following the incidents, potentially allowing for the identification of a process of single-loop learning. This will allow for recognition and analysis of the initial major changes within regulatory and inspection policy. In outlining the practice alterations made, the analysis will attempt to identify indicators of a process of learning taking place within this case phenomena based on the theories outlined in the body of knowledge. Taking a similar approach to that of Smith and Elliot by analysing the developments made to safety and then judging the degree of learning exhibited, by applying the concepts of single and double loop learning. Thus, naturally facilitating the thesis’ ability to judge the degree of organisational learning as a causal mechanism within the specific attempts to improve safety and organisational resilience.
The second analysis chapter will specifically focus on how policy towards stadium design and layout has developed and changed since the disasters. This topic of policy change was chosen due the numerous examples of policies aimed at addressing this issue over the last 30 years. The chapter will first focus on the policies in place before the disasters and attempt to understand how these failed to prevent their occurrence, paying particular attention to the Hillsborough disaster as the stadium design was a key cause of the incident. This allows the analysis to focus on the imminent changes that followed, aiding identification of the immediate adaptations of policy. Inspecting the changes to certain regulations and then applying the concepts relating to the differing degrees of learning, authorizes the thesis to judge the degree of the learning process within the organisational development, through attempting to identify theories of organisational learning within the adaptations made to this topic of safety policy.
The third analytical chapter will investigate attempts to improve safety through analysing changes within the production of guidance and the development of research methods within the industry. Focusing on the leading producers of guidance, namely the SGSA will allow the thesis to understand how the production of guidance has developed since the publication of the first Green Guide up until the current day. Doing this not only allows for a reflection of the actual content of these updated guides but also the methods of research behind the adaptations. Inspecting how the industry has been led over the time periods, naturally allows
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the thesis to judge how competent and how reflective the leading organisations have been within guiding and updating safety practices within the UK football industry. Assessing this long-term updating process the thesis will be able to identify indicators of organisational learning and to reflect on the degree to which a learning process takes place within the attempts to develop safety guidance and research.
Facilitating Aspects to Analysis
To aid the identification of learning processes within developments to safety and resilience, aspects of a framework for improved safety and risk management concerning resilience will be utilized and adapted to further guide the thesis within its analysis. Focusing the analysis on how the industry addressed the highlighted aspects for the successful development of resilience policy and practices, will allow the thesis to interpret and identify whether these organisations reflected on previous experiences/events and applied this knowledge to improve their approach. In analysing these factors in the framework, the analysis will also be able to assess the visibility of a process of learning within the industry’s approach, granting the thesis, a basis to judge the extent to which the UK football industry has exhibited organisational learning.
The aspects of resilience within this framework are used and built upon as discussion points for analysing the industry’s approaches to specific cases of safety and resilience policy adjustments. This is done so as to identify and assess the level of reflection and inclusion of past experiences as indicators of learning within the functioning of the industry towards improving resilience and self-regulation practices concerning safety. The framework in question is the ‘Process Resilience Analysis Framework’, which is designed for analysing the resilience and safety practices of process industries such as chemical plants, oil and gas platforms. The concept of resilience within this framework relates to the formation of policy and practices that allow for the avoidance, survival and recovery following disruptions.66 Placed in the context of the UK football industry these disruptions encapsulate incidents from major disasters to minor questions of safety.
The objects of interest in this framework are the four aspects of resilience identified as cornerstones of competence within policy and practice regarding safety. The first aspect of resilience refers to the ‘early detection’ ability of a system. This relates to a system’s ability to
66 Jain, Prerna, Hans J. Pasman, Simon Waldram, E.n. Pistikopoulos, and M. Sam Mannan. “Process Resilience
Analysis Framework (PRAF): A Systems Approach for Improved Risk and Safety Management.” Journal of Loss Prevention in the Process Industries 53 (2018), 67.
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recognise weak signals within the adaptation of policy for safety.67 Focusing on the development of approaches towards this in respect to the UK football industry will aid the thesis in identifying whether a learning process took place. Confirmation of this learning process having occurred should be outlined within implemented policies addressing the early warnings that were missed within the previous disasters.
The second element of ‘error tolerant design’, implies that following a disaster or event, the policies and systems of resilience are made safer through adapting policy so that the system cannot fail again in the same manner.68 Improvements to safety should be made, so that the level of damage is lessened should a similar undesired event reoccur. An indicator of this may be an instance of policy where extra safety measures and procedures are pursued following an incident, so as to mitigate the harm caused should the error reoccur. In the case of the UK football industry such indicators of learning within this concept may be to significantly decrease the capacity of a certain area of a stadium after incidents of overcrowding. This would mean that should over-crowding within that particular section reoccur, the consequences should not be as damaging due to the reduction in capacity in that specific section.
The third element is the aspect of ‘recoverability’ which concerns the policies ensuring that a system can recover quickly and efficiently following a disaster or crisis event.69 Indicators of a process of learning within this aspect would therefore be highlighted by the implementation and development of new response policies based on reflections made regarding previous crisis responses. Evidence of a reflection on the responses of the industry to the disasters of the 1980s would have to be clearly considered in the formation of new recovery procedures and policy, so as to highlight a case of organisational learning in this aspect of development.
The fourth aspect concerns ‘plasticity’ otherwise characterised as flexibility within an organisation’s resilience and safety practices.70 This concept refers to how competent an organisation is in adapting its policy to when new issues arise. Furthermore, the aspect also encapsulates the ability and ease at which the structures and individuals within the organisation evolve to changes within policies and structures. Learning within this concept would be indicated by structures being placed to facilitate smooth adaptations to policies according to
67 Ibid. 68 Ibid. 69 Ibid. 70 Ibid.
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changes in the environmental situation, based on observations of how well previous cases of ad-hoc policy were carried out.
Data
The objects of analysis primarily concern reports, official statements and research conducted concerning safety by the FA and SGSA, the use of these sources will allow the thesis to gain an understanding of how the norms, procedures and attitudes towards safety have developed within the industry over the time period. These sources are also important in the identification of how the industry reacts to specific incidents of disruptions and minor incidents effecting safety over the period. This allows the analysis chapters to judge the extent of reflection and learning seen within how the industry acknowledges and approaches a specific incident.
Further objects of analysis concern the developments within safety and regulatory policy within the industry. This consequentially means that the updates made to the Guide for Safety at Sports Grounds (Green Guide) written by the SGSA will be a central source of focus. The guide itself provides advice concerning the management and design of football stadiums for the safety of supporters. The first edition of this guide was written in 1973, and was first updated following the Valley Parade disaster. Notably, in 1989 the third edition was published in response to the Hillsborough disaster. Thus, allowing the thesis to identify the shortcomings within the policies prior to these major incidents, as well as to highlight and assess the changes in policy following these events. In addition to the Green Guide changes during this period, the analysis will also utilise the Popplewell inquiry into the Valley Parade disaster and Hillsborough report and various other guidance documents, to analyse and understand the causes and failures within the pre-existing safety policies within these incidents. Since the 1989 edition the guide has been updated three times respectively in 1997, 2008 and 2018. Therefore, the relevant changes and developments within the policies of interest to the analysis chapters will of course be mapped out and studied to understand the reflective nature of these updates.
Supplementing the official guidelines and research, the thesis will also analyse reports from the British media regarding instances where policy enforcement or review is required regarding safety, examples of such would be the research focused on the introduction of ‘safe-standing’. Inspecting the industries approach to these instances where safety policy is called into question will facilitate the identification of the learning processes and roots behind the industry’s stance on certain cases.
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Chapter 4 - The Disasters and The Development of Safety Policy and
Regulation
Prior to the Disasters
To understand the process as well as to judge the degree of organisational learning within the UK football industry, the safety structures and regulatory practices in place prior to the disasters of the 1980s must be outlined and discussed, this is done to form a logical foundation to highlight the developments made in the industry. The chosen starting point for this process of safety and regulatory policy development within the UK football industry takes place during the 1970s with the implementation of the 1975 Safety of Sports Grounds Act. This piece of legislation set the groundwork for the formation of a regulatory system for safety in football stadiums throughout the UK. The act required all designated stadiums with a capacity for holding over 10,000 supporters to acquire a licence and certification of safety, enabling them to host supporters for sporting events.71 The legislation required that the designated club’s grounds must fulfil a number a of safety requirements so as to receive certification. Examples of key requirements include the setting and documentation of a maximum capacity, as well as the maximum capacity of individual stands and sections of grounds.72 Further key requirements related to the size of entrances and exits meeting a minimum height and width, including emergency escapes in accordance to the act and minimum strength thresholds of crash barriers and fences.73 Alongside these more physical specifications, the act also introduced the data accounting obligations for clubs, such as the compulsory recording of accurate attendances at matches, together with the need to log all developments made to structures and entities within the ground.74
To help implement these newly imposed safety criteria, the act made local authorities these being county and borough councils, the responsible body for issuing safety certificates and licences to the designated stadiums within their jurisdiction.75 In doing so, the act also granted local authorities the ability to replace, make amendments to and alter the status of safety certificates given to clubs should the standard of safety within the ground fail to comply with
71 Government of the United Kingdom. Safety of Sports Grounds Act 1975. London. 1975. Section 1. 72 Ibid, section 2.
73 Ibid.
74 Ibid, section 2,3.
75 ‘Safety Certification - Sports Grounds Safety Authority’. Sports Grounds Safety Authority.
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the specifications in the act.76 Notably, this also admitted local authorities with the power to impose emergency measures and responses to a breach in safety standards, for example sections of stadiums could now be closed, should a club fail to comply with the legislation.77 Designating this responsibility to local authorities consequentially authorized these bodies with the power of inspection within stadiums, essentially obliging them to do so.78 In addition, the act also allowed the authorities to the ability to pursuit legal actions against clubs via law enforcement measures should a local club choose to violate the legislation by operating without a valid licence.79 This is an area of the industry’s functioning that underwent a drastic amount of change in the period following the disasters, which will be analysed in depth within the analysis to judge the degree of learning exhibited within the industry.
Following the implementation of the Safety of Sports Grounds Act, came the publication of the first edition of the Guide to Safety in Sports Grounds in 1976, also known as the Green Guide.80 The creation of this guidebook came as a result of Lord Wheatley’s report on the 1971 Ibrox disaster in Scotland. After compiling the report on the crush in which 66 people were killed on an exit stairway following a Glasgow Rangers game, Wheatley deemed it necessary to issue a guiding document for both clubs and local authorities regarding the imposing of a proper standard of safety in stadiums.81 Notable within this publication is its purpose purely as a guidance document produced with the aim of achieving a standard guideline for safety, this meant that clubs could simply choose to ignore advice and recommendations provided. This disregard of the guidance happened on a number of occasions and will be something which will be more directly highlighted within the following analysis paragraphs, referring to how this phenomenon contributed to the occurrence of the major disasters.
Assessing the regulatory structures in place before the disasters of the 1980s the introduction of some regulatory legislation in the form of the 1975 Safety at Sports Grounds Act does highlight a proactive step towards attempting to provide a sufficient process. Yet, it is clear that the system of ensuring safety in stadiums existed primarily on a basis of self-regulation between local authorities and clubs, possibly due to the non-existance of an over-sight body to enforce compliance of both clubs and local authorities. This meant that the relevant organisations had a great deal of discretion and flexibility within the manner of
76 Safety of Sports Grounds Act 1975, Section 4. 77 Ibid, Section 10.
78 Ibid, Section 11. 79 Ibid, Section 12.
80 Hillsborough: the Report of the Hillsborough Independent Panel. London: The Stationery Office, 2012, 30. 81 Elwood-Stokes, Caroline. Football Disasters: The Moments We Will Never Forget, 2019,1.
