Organizational Learning for Crisis
A
N ANALYSIS OF THED
UTCHM
INISTRY OFD
EFENCEMaster Thesis Crisis & Security Management Written by: Kimberley Kruijver
Student number: S1224719 Date of admission: 09.01.2018
Word count including appendix: 24.090 words Word count excluding appendix: 19.093 words Thesis supervisor: W.G. Broekema
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Table of Content
List of Abbreviations………..…...3 1. Introduction………..…………...4 2. Theoretical Framework……….………...7 2.1 Defining ‘crisis’……….……...……….7 2.2 Organizational learning……….………...…………..72.3 Normal accidents and high reliability organizations….…...………10
2.4 Military organizations……….………...…..12
2.5 Factors influencing organizational learning………...…..13
2.5.1 Knowledge management ………...………...…….……...13
2.5.2 Resistance to change ………..…….……….14
2.5.3 Organizational culture.………...………...16
3. Methodology………. 17
3.1 Research design………...……… 17
3.2 Case study selection……….…17
3.3 Data gathering and analysis...………...18
3.4 Operationalization of variables….………...20
3.5 Reliability, validity and limitations….……….23
4. Analysis……….25
4.1 Incident reports 336 Squadron Royal Air Force………..………25
4.1.1 Knowledge management ………...……….…..26
4.1.2 Resistance to change ………..………..……….28
4.1.3 Organizational culture.………...………...29
4.1.4 Sub-conclusion………. 30
4.2 Ossendrecht shooting incident………...………..31
4.2.1 Knowledge management ………...……….…..32
4.2.2 Resistance to change ………..………..……….35
4.2.3 Organizational culture.………...………...36
4.2.4 Sub-conclusion………. 37
4.3 Mortar accident Mali………...……….………37
4.3.1 Knowledge management ………...……….…..38 4.3.2 Resistance to change ………..………..………44 4.3.3 Organizational culture.………...………...46 4.3.4 Sub-conclusion………. 46 4.4 Case comparison………..47 5. Conclusion……….………50 6. Bibliography………..……52 Appendix 1………...….56
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List of Abbreviations
AAR After Action Review
ABWM Afdeling Beproevingen Wapensystemen & Munitie (department Trials Weapon Systems and Ammunition)
AMV Algemeen Militair Verpleegkundige (General Military Nurse)
ASR Air Safety Report
BATLS Battlefield Advanced Trauma Life Support
CLAS Commando Landstrijdkrachten (Land Forces Command) CvO Commissie van Onderzoek (Committee of Investigation) CQB Close Quarters Battle
CRM Crew Resource Management
CT Counter Terrorism
DCR Damage Control Resuscitation
DCS Damage Control Surgery
DMO Defensie Materieel Organisatie (Defence Materiel Department)
DSB Dutch Safety Board
DOPS Direction Operations FMS Foreign Military Sales HRT High Reliability Theory HRO High Reliability Organization
IMG Inspectie Militaire Gezondheidszorg (Inspection Military Healthcare) JOLI Joint Operational Logistic Instruction
KCT Korps Commando Troepen (Royal Dutch Army’s Commando Corps) KMCGS Korps Militaire Controlleurs Gevaarlijke Stoffen (Corps Military
Inspectors Dangerous Substances) LOA Letter of Offer and Acceptance
MAR-OPS 1 Military Aviation Requirements for Fixed wings transport, tanker and maritime surveillance operations
MCGS Militaire Commissie Gevaarlijke Stoffen (Military Commission for Hazardous Materials)
MINUSMA Multidimensional Integrated Stabilization Mission in Mali MoD Ministry of Defence
NAT Normal Accidents Theory
OM-A Operation Manual Air Mobility ORM Operational Risk Management PRM Personnel Risk Management
RAF Royal Air Force
RI&E Risk-Inventory and –Evaluation SOP Standard Operating Procedures
TC Type Classification
TDL Toezicht Defensieleveranciers (Supervision Defence Suppliers) TOP Tactical Operating Procedures
TPRS Towed Paratrooper Retrieval System
UN United Nations
US United States
USASAC US Army Security Assistance Command
VMS Defensie Veiligheid Management Systeem Defensie (Safety Management System Defence)
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1. Introduction
On 6 July 2016, the Dutch Ministry of Defence (MoD) announced that two army soldiers had lost their lives and one was seriously injured during a firing exercise with mortars in Mali.1 Earlier that year the MoD already made headlines when a sergeant died during a shooting exercise of the Royal Dutch Army’s Commando Corps (KCT).2 These types of accidents are not new and led to the question how it is possible that military men lose their lives during professional exercises. This question was widely discussed in politics and media, after the Dutch Safety Board (DSB) had published their investigation on the mortar accident in Mali.3 The study concluded that the MoD had made multiple mistakes that ultimately caused a crisis. The publication intensified public concern about the ability and willingness of the MoD to learn from their mistakes. The discussion came to a climax when the Minister of Defence Hennis and the highest-ranking military officer Commando der Strijdkrachten Middendorp stepped down.4 When the Netherlands formed its new cabinet last year, the MoD received, for the first time in seven years, a Secretary of State (Visser) in addition to a new Minister (Bijleveld). The reason for the supplementary political functionary was to solve all the ‘problems’ within the MoD.5 These problems not only concern a shortage of personnel and materiel, but also the recurrence of similar incidents and hence the failure to learn from them. This issue sparked a discussion to which extent the MoD can call itself a ‘learning organization’.
Much has been written on learning organizations and the learning processes within an organization, so-called ‘organizational learning’ (Argote 2013; Broekema 2016). Nonetheless, only a limited number of studies have linked ‘organizational learning’ to national ministries, or more specifically the Ministry of Defence (Bechtel 2017). Up until now, the learning processes within military organizations are not well understood. Furthermore, the ‘organizational learning’
1 Royal Netherlands Army (06.07.2016) “2 Dutch military personnel killed in Mali”
https://www.defensie.nl/english/organisation/army/news/2016/07/06/2-dutch-military-personnel-killed-in-mali, accessed on 16.09.2017.
2 NOS (22.03.2016) “Militair omgekomen bij schietoefening Ossendrecht”
https://nos.nl/artikel/2094524-militair-omgekomen-bij-schietoefening-ossendrecht.html, accessed on 16.09.2017.
3 Dutch Safety Board (2017) Mortierongeval Mali
https://www.onderzoeksraad.nl/nl/onderzoek/2242/mortierongeval-mali
4 NOS (03.10.2017) “Hennis treedt af om dodelijk ongeval Mali”
https://nos.nl/artikel/2196095-hennis-treedt-af-om-dodelijk-ongeval-mali.html, accessed on 29.10.2017.
5 NOS (27.10.2017) “Barbara Visser (VVD) moet problemen op Defensie gaan oplossen”
https://nos.nl/artikel/2199540-barbara-visser-vvd-moet-problemen-op-defensie-gaan-oplossen.html, accessed on 14.12.2017.
5 stream in the literature predominantly focuses on learning during a crisis or during “times of war” (Bechtel 2017; Catignani 2014). The problems within the MoD however concern issues of learning prior to crises.
This research wants to delve into the recurrence of incidents at the MoD and connect this phenomenon to ‘organizational learning for crisis’ (Smith & Elliott 2007: 522). It thus focuses on the learning processes within the military organization, before crises – such as the shooting incidents – occur. Moreover, this study aims to find out what affects these learning processes. Based on a literature review, three factors are identified that are likely to affect the organizational learning process for crisis at the MoD: ‘knowledge management’, ‘resistance to change’ and ‘organizational culture’. Subsequently, this thesis questions to what extent these factors influence the process of for crisis learning at the MoD. The proposed research question therefore is: “To what extent do the factors ‘knowledge management’, ‘resistance to change’
and ‘organizational culture’ influence organisational learning for crisis at the Dutch Ministry of Defence?”.
The study is conducted by analysing DSB investigation reports of three cases: the incident reports at the 336 Squadron Royal Air Force (RAF)6, the Ossendrecht shooting incident7 and the mortar accident in Mali. These cases include the most recent (investigated) incidents and crises at the MoD. The information in the reports is analysed by looking for indicators of learning processes for crisis and the contributing factors. Based on this analysis an answer to the research question is formed.
The societal relevance of this research is that it connects the problem of repetitive safety incidents within the Dutch military to learning. This problem has gained wide publicity and had great socio-political consequences. The latest DSB publication (2017b) could have multiple implications for the armed forces, such as an even more reduced attraction of applicants. Above all, the practical relevance for military personnel emerges from the importance of pre-crisis learning for their safety. Military employees encounter more safety risks than most other professions. Understanding what influences ‘for crisis learning processes’ improves the ability
6 Dutch Safety Board (2014) “Incidentmeldingen 336 Squadron Koninklijke Luchtmacht”
https://onderzoeksraad.nl/nl/onderzoek/1981/incidentmeldingen-336-squadron-koninklijke-luchtmacht
7 Dutch Safety Board (2017) “Veilig oefenen, lessen uit schietongeval Ossendrecht”
6 to adequately deal with a crisis if it occurs. Therefore, this research is of importance to military organizations and its personnel.
The academic relevance of this research is that it concentrates on organizational learning for crisis, which is a relative new field.In addition, pre-crisis learning has not yet been researched within the MoD. This research will contribute to the general body of knowledge on ‘organizational learning’ within national ministries and high reliability organization’s (HROs). For specifically military organizations, this study will add to the debate on the general assertion that military organizations are resistant to change (Davidson 2010: 10). It will try to connect the for crisis learning processes to the dominant organizational culture of HROs.
This thesis is structured as follows. In the following chapter, the theoretical framework is outlined. It discusses relevant theoretical contributions on ‘organizational learning for crisis’ and the functioning of HROs and specifically military organizations. This provides the theoretical foundation from with the factors ‘knowledge management’, ‘resistance to change’ and ‘organizational culture’ are drawn. These factors are expected to influence pre-crisis learning. The third chapter describes the research design and research methods. Furthermore, it operationalizes the important concepts for this study and discusses the study’s reliability, validity and limitations. The fourth chapter presents the empirical analysis on the case studies before comparing them. Finally, the fifth chapter contains the conclusion, including an answer to the research question, a brief discussion and recommendations for further research.
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2. Theoretical Framework
The theoretical framework is based on literature concerning ‘organizational learning for crisis’ and theories on the occurrence of accidents across organizations. Furthermore, it places the literature in the context of specifically military organizations. Relevant concepts related to organizational learning, HROs and military organizations are defined and discussed. This leads to three factors that are expected to influence to what extent a military organisation learns, namely: ‘organizational culture’, ‘knowledge management’ and ‘resistance to change’. In the final three sub-sections, the relation between these factors and organizational learning for crisis are outlined.
2.1 Defining ‘crisis’
Before the relationship between ‘organizational learning’ and ‘crisis’ can be discussed, the concept of ‘crisis’ needs to be explained. Crises are defined in different ways, depending on the context of the research. In general, the definitions contain three components: threat, urgency and uncertainty. Boin et al. (2005: 2) argue that “crises occur when core values or life-sustaining systems of a community come under threat”. This definition refers to values such as safety and security, welfare and health, integrity and fairness that become unstable or even meaningless because of violence, destruction, damage or other forms of adversity (Boin et al. 2005: 3). The crisis goes deeper when more lives are governed by the values under threat (Boin et al. 2005: 3). Furthermore, crises induce a sense of urgency. Policymakers tend to deal with threats that pose immediate problems (such as a terrorist attack) as opposed to threats without a sense of urgency (such as climate change), since the former require their instant attention (Boin et al. 2005: 3). Finally, a crisis contains a high degree of uncertainty, which refers to the nature and potential consequences of the threat and the way people responded to it (Boin et al. 2005: 3).
2.2 Organizational learning
No universally accepted definition of ‘organizational learning’ is available. In academia, ‘organizational learning’ is viewed from both a cognitive and a behavioural perspective (Argote 2013; Broekema 2016). These perspectives define organizational learning as a change in either cognitions or behaviour. However, studies argue that both perspectives should be combined. Researchers acknowledge that organizational learning takes place when a change in the organization’s knowledge occurs as a function of experience (Argote 2013: 31). Broekema
8 (2016: 383) combines the two viewpoints for the following definition: “the enhancement of organizational performance (behaviour) based on newly acquired knowledge (cognition)”.
A distinction can be made between ‘formal learning’ on the one side and ‘informal learning’ on the other side (Bechtel 2017; Catignani 2014). Formal learning is concerned with the process(es) generated by institutionalized learning mechanisms, such as military policy. Institutions can force formal learning by demanding the collection, consolidation and distribution of professional and operational feedback. These institutionalized learning mechanisms drive formal learning to finalization, with the outcome of new or updated doctrines, institutions and practises (Bechtel 2017: 22). According to Bechtel (2017: 22), the most apparent indicator of formal learning in the military is the conduct of an After Action Review (AAR); “a structured debrief and collective reflection process used to analyse and propose recommendations for future training and operations”. Formal learning happens incrementally as a reaction to lessons learned over time. As such, formal learning is a reflective process, which responds to experienced events (Bechtel 2017: 22).
Informal learning happens outside of formal channels and is a product of a ‘learning ethos’, like individual knowledge (Bechtel 2017: 23). According to Bechtel (2017: 23), “an effective learning ethos prompts learning outside of structured channels, with larger social and professional rewards as learning becomes habitual and instinctive”. Downie (1998: 24) argues that individual informal learning is necessary for institutional learning, which occurs when organizations institutionalize lessons learned by their members (Downie 1998: 23). However, institutional learning is not enough for institutionalization to occur. Institutionalization and thus organizational learning only happens when the lessons learned are “widely accepted, shared, and practised as standard procedure by members throughout the organization” (Downie 1998: 24). Indicators of informal learning include the discussion of the failures and successes of events amongst professional and social networks as well as individual attention to personal and collective experience. Informal learning depends on the presence of experienced individuals, which means that the process happens sporadic and non-cumulative (Bechtel 2017: 24). Bechtel (2017: 55) contends that informal processes are often difficult to identify, because they are unstructured and often undocumented.
Smith and Elliott (2007) analyse the interaction between organizational learning and crisis. The authors differentiate between three types of relationships: ‘learning from crisis’ (after the crisis
9 took place), ‘learning as crisis’ (during the crisis takes place) and ‘learning for crisis’ (before the crisis takes place) (Smith & Elliott 2007: 522). Each relationship can be seen as a phase that is succeeded by the next one. This thesis focuses on the latter; organizational learning for crisis. This period can be considered the first stage of a crisis and is characterised by ‘crisis of management’ (Smith & Elliott 2007: 520). According to Smith and Elliott (2007: 520), the regular management processes in this phase, predominantly around decision-making, create the conditions for crisis incubation. The emphasis in this stage is on the role of management, which plays a major role in the potential development of crises. Organizational and human factors can be combined in such a way that a culture prone to crises is created. The goal of learning for crisis is “developing the ability to deal with crises as they occur” (Smith & Elliott 2007: 524). An organization can accomplish this aim by considering various scenario’s during the pre-crisis of management stage (Smith & Elliott 2007: 525).
Furthermore, Smith and Elliott (2007: 523) discuss ‘pathways of vulnerability’, which are inherent to an organization’s cultural norms and assumptions. ‘Vulnerability’ is defined as “the generation of both latent and active errors and the conditions through which system emergence occurs” (Smith & Elliott 2007: 523). The cultural properties can create conditions for which no protocols exist, or which surpass the levels of tolerance that are part of controls. These conditions are the latent errors. The gaps within controls can be seen to be created by management actions and decisions, which subsequently provide the conditions for incidents to escalate into crises. When the emergent properties are generated and the controls are circumvented, managers have to ‘make sense’ of events and take appropriate action. The capability to choose the best course of action after a crisis is the goal of for crisis learning. The pathways of vulnerability are part of each phase of the crisis management process and “can remain ‘hidden’ until the emergence that generates them exposes the latent management errors that have created the ‘climate’ in which the crisis was ‘triggered’ and the resulting gaps and limitations in control mechanisms” (Smith & Elliott 2007: 523). These pathways can be generated in each phase of a crisis and are interconnected over space and time. Their interconnectedness makes it difficult to detect and eradicate them. Smith and Elliott (2007: 524) summarize that pathways of vulnerability can originate because of four reasons. The first one is latent decision-making within the organization, such as groupthink and other team-based psychological barriers. The second reason includes problems related to the culture of the organization. The third one involves failures to take account of changes made to core procedures and protocols, which leads to the exposure of the limitations of control mechanisms.
10 The fourth reason is the inability or unwillingness to learn from crisis events (internally or externally).
2.3 Normal accidents and high reliability organizations
Cooke (2003) argues that many ‘disasters’8 occur because organizations disregarded warning signs of ‘precursor incidents’ or failed to learn from prior lessons. The ability to learn, to effectively share and synthesize information from ‘precursor incidents’ with relevant people across the organization, aids in taking the right course of action to minimize the risks of disasters to happen (Cooke 2003: 2). The same can be argued about the wider scope of crises. Two organizational theories have analysed the occurrence of accidents in organizations and stress the importance of learning from them: Normal Accidents Theory (NAT) and High Reliability Theory (HRT). Moreover, each of them view the problems related to organizational learning differently. It is important to discuss these organizational theories, because they provide insights into the functioning of organizations, including potential enablers of and barriers to organizational learning (for crisis).
The pre-crisis learning process, as described by Smith and Elliott (2007), can be linked to NAT. NAT is an organizational theory that argues that in systems with certain organizational characteristics, accidents can be ‘normal’ (Perrow 1984). In this theory, accidents are the predictable outcome of the organization’s normal functioning. Pathways of vulnerability are in this sense unavoidable. Perrow (1984) argues that in systems characterised by ‘complexity’ (irreversible processes and multiple, non-linear feedback loops) and ‘tight coupling’ (actions in one part of the systems directly influence other parts of the organization) small deviations or human errors can combine in a way that leads to a cascade of failures. This cascade in turn leads to system accidents. Similarly, Smith and Elliott (2007) describe how decisions and actions in management can create latent errors, which in turn lead to crises. Perrow’s (1984) solution to such accidents is to combine centralization (dealing with tight coupling) with delegation (dealing with complexity). Highly complex and tightly coupled systems are confronted with conflicting demands: they need centralization and decentralization at the same time. On the one side, specific knowledge of local disturbances is needed and on the other side, these systems are in need of overview of critical interdependencies between parts of the system. With the help
8 Cooke (2003: 2) defines ‘disaster’ as “a very serious incident involving loss of life and/or extensive property
11 of organizational learning processes the small deviations may be recognized, which can prevent organizational failures and crises. However, the NAT perspective claims that organizations are always at risk of such failures and crises, no matter how much learning occurs. This means that human errors are inevitable.
High Reliability Theory (HRT) was formulated in response to NAT. Weick (1987) contends Perrow’s (1984) assumption and states that a strong ‘organizational culture’ can supply a centralized and focused cognitive system within which delegated and loosely coupled systems can function effectively. This culture provides a common awareness of potential vulnerabilities. According to HRT, pathways of vulnerabilities can thus be recognized through an established ‘culture of reliability’. In this culture every person and component in the system acts reliable, so no accidents take place (Marais et al. 2004: 12). HRT asserts that learning from errors can improve managerial practises and increase safety conditions within complex, high-risk organizations. Organizational learning, more specifically learning for crisis, is thus an integral part of the reliability culture. High-risk organizations become transformed into high reliability organizations (HROs). HROs are defined as complex organizations engaged in high-hazard activity that continually face unexpected developments, but “manage to have fewer than their fair share of accidents” (Weick & Sutcliffe 2011: 17). According to Weick (1987), accidents occur because the people who manage the complex ‘systems’ are not complex enough to sense and anticipate the system’s problems. His solution is more variety among the people in a system, like an organization. Weick and Sutcliffe (2011) identify five principles for HROs to anticipate the unexpected and practise successful problem management. First, HROs have a preoccupation with failure. This includes the use of failure to attain insights into strengths and weaknesses of the system. Second, HROs are reluctant to simplify, which means that they avoid minimizing or explaining away problems. The third principle is the sensitivity to operations. This involves the awareness of how all components in the system fit together and are interrelated to each other (meaning that problems can easily spread throughout the system). Fourth, HROs are resilient, which refers to the capability to deal with un-expected events. The fifth principle is deference to expertise. HROs know where the expertise is in the organization and employ the relevant experts to handle with problems. Jointly, these principles are labelled ‘collective mindfulness’ and increase the comprehension of complexity and loosen tight coupling (Weick & Sutcliffe 2011). It is important to emphasize that the specific context of an organization, including its resources and constraints, influences the processes and practises that enact these principles (Schulman 1993). Thus, every type of organization has its own challenges of becoming an HRO.
12 Based on the discussed literature, this thesis adopts the assumption that errors and incidents, including accidents, happen in highly complex and tightly-coupled systems. However, by incorporating certain business processes, or ‘collective mindfulness’, organizations can learn from incidents before a crisis occurs. This happens in the ‘pre-crisis of management’ stage (Smith & Elliott 2007: 525).
2.4 Military organizations
As discussed above, every organization operates in a unique context. Consequently, organizational learning varies per type of organization. For this thesis it is important that the specifics of military organizations are discussed to provide a thorough theoretical background for the analysis.
Military organizations are unlike other organizations. On the one side, they operate in peacetime where they deal with routines and thereby resemble ‘conventional’ organizations. On the other side, they operate in crisis and peace operations or war. It is mainly in the latter context where military organizations significantly differ from other organizations (Soeters et al. 2010: 1). First, military organizations are authorized by the state to use violence. Second, they have to perform in very dynamic and high-risk environments where they have to deal with ambiguous, imperfect or false information (Marais et al. 2004). Soeters et al. (2010: 1) argue that even in peacetime, military organizations are unlike other organizations, because of three characteristics. The first one is the communal life of military personnel. The military employees, and often their families, mostly live in military housing, which is separated from ordinary life. The second characteristic is the hierarchy, a consequence of the military bureaucracy. The power comes from the top of the organization and trickles down. Third, military organizations are characterised by discipline, which includes compliance with the rules, acceptance of authority and orders and overt punishment in the case of disobedience (Soeters et al. 2010: 1). Additionally, military organizations are distinguished by ‘interactive complexity’ and a ‘tight coupling of activities’ (Bijlsma et al. 2010: 228). Military trainings or operations can be conceptualised as ‘systems’ that are highly interactive and complex. According to Tavana et al. (2012: 171), the interactive complexity and tight coupling between people and technological systems has been increasing in military operations, which leads to unpredictability and ultimately failures.
13 The specific features of military organizations influence the process of organizational learning for crisis. If military organizations are defined as HROs, their success depends on their organizational learning capability. Since military organizations are characterised by their use of violence and operations in dynamic and high-risk environments, they cannot afford to learn from trial and error. To learn and improve dealing with crises if they occur, militaries have to “use imagination, vicarious experiences, stories, simulations, and other symbolic representations of high risk situations” (Bijlsma et al. 2010: 228).
2.5 Factors influencing organizational learning
Based on the literature concerning learning for crisis, the occurrence of accidents across organizations and the specificity of military organizations, three factors that are expected to influence organizational learning at the MoD are identified. NAT stresses the function of human factors, which incorporates multiple errors humans can make. This study integrates the role of human factors in the factor ‘knowledge management’. The second factor is the ‘resistance to change’ and follows from the (bureaucratic) characteristics of a military organization. Lastly, HRT emphasizes the prominent role of an organization’s ‘organizational culture’, which constitutes the third factor. Furthermore, all three factors are mentioned by Smith and Elliott (2007: 524) as possible causes of pathways of vulnerabilities.
2.5.1 Knowledge management
The first factor is ‘knowledge management’, which includes the collection, transfer and integration of knowledge (Catignani 2014: 32). Catignani (2014: 35) argues from a knowledge-based viewpoint that organizations are “repositories of knowledge” which is embedded in structures, rules, standard operating procedures (SOPs), mental models and dominant thinking. The challenge is successful knowledge managing to exploit current knowledge and to explore new knowledge to consequently institutionalize it and achieve organizational learning (Catignani 2014: 35). Changes to the knowledge repositories requires institutional learning, whereby lessons learned are incorporated into ‘organizational routines’.
There are three stages in the knowledge creation and learning process (Catignani 2014: 36). The first stage includes data collection through formal data collection systems, such as interviews, and informal learning systems, like social networks. Second is the interpretation of the collected data, which is defined as “the process by which meaning is given to information”,
14 whereby shared understandings of experiences are developed (Catignani 2015: 36). The interpretation process is highly subjective and context dependent. The gathered information is framed, which influences the interpretation. Furthermore, interpretations are shared through communication. This means that interpretation depends on the capacity and willingness of the individual or unit to process information (Catignani 2014: 37). The third stage is when organizational learning happens. Based on interpretation, knowledge is institutionalized and a new response or action is developed.
The outcome of successful knowledge management is the incorporation of knowledge in organizational routines, which equals formal or informal learning. For the sake of clarity, this thesis defines ‘knowledge management’ as the formal and informal collection and transfer of new and current knowledge. This factor thus refers to the question of how the organization and its employees explore and exploit new and current knowledge before any changes to organizational routines are made.
Knowledge management can affect the process of organizational learning for crisis, since effective knowledge management is necessary for the institutionalization of knowledge. Lessons learned are stored in individuals or in organizational knowledge repositories. Their ‘permanence’ depends on what personnel leave behind when they leave or transfer within the organization (Catignani 2014: 36). When newly acquired knowledge is not incorporated in organizational routines, it is lost as soon as personnel moves on or leaves the organization (Catignani 2014: 32). This loss is termed “organizational forgetting” (Catignani 2014: 39). When knowledge is lost, the organizational learning process is hindered, because the unit may fall back on former routines and underlying assumptions (Catignani 2014: 39). Within the MoD, military personnel change their job every three years.9 This dynamic structure makes it more difficult to incorporate new knowledge into the organization.
2.5.2 Resistance to change
The second factor that is expected to influence organizational learning for crisis at the MoD is ‘resistance to change’. The concept ‘resistance’ lacks a systemic definition and can be used to describe actions at the individual, collective of institutional level (Hollander & Einwohner
9 Ministerie van Defensie: Sociaal Beleidskader Defensie 2012-2016
15 2004). Bauer (1991: 9) defines ‘resistance to change’ as “an informal way of expressing conflict. It is conflict awareness and behaviour which is not anticipated in form and content by the change agency”. Organizational learning is said to take place when a change in the organization’s knowledge occurs. Consequentially, resistance can be the outcome of learning, but it can also be a barrier to it (Alas & Sharifi 2002: 317). Resistance to change in (public) organizations can be conceptualized from a psychological, structural, power or dialogic perspective (Symon 2005). Overall, it is seen as a natural reaction, which is caused because individuals are fearful, are inherently resistant to, or misunderstand the change (Symon 2005: 1642). Resistance is viewed as a negative response of employees that hinders organizational change, and thus learning. Thomas et al. (2011: 35) demonstrate that resistance can also facilitate organizational change and can even play a bigger role in supporting organizational change than absolute acceptance. So-called ‘facilitative resistance’ necessitates counteroffers by the group that initially proposed the change (change agents) as well as by the group that resists this change (change recipients) (Thomas et al. 2011: 35).
Resistance to change can influence for crisis learning, because the negative attitude acts as a barrier to it. The relevance of this factor for the military context can be explained from two perspectives. First, organizational theory views military organizations as highly resistant to change (Allison 1999; Halperin & Clapp 2007). Davidson (2010: 11) summarizes this argument by stating that structural systems, norms and SOPs within a military organization will likely counter change, even if actors within the organization desire for it. These structural mechanisms are closely related to the organizational culture, since the latter emerges from the routines that reinforce norms (Davidson 2010: 11). Burr (1998: 9) argues that the organizational culture of militaries generally is conservative and thus resistant to change. According to this perspective, the structures and processes that produce strategy and doctrine must be changed in order for the military organization to learn (Davidson 2010: 11). Second, bureaucratic politics theory argues that military leaders want to promote the importance of their organization and to safeguard the organizational ‘essence’. This essence refers to “the view held by the dominant group in the organization of what the missions and capabilities should be” (Halperin & Clapp 2007: 27). Thus, every change that challenges the essence will be rejected by the organization. This theory expects military organizations to resist change when it does not enhance the stature or relevance of the organization (Davidson 2010: 13).
16 2.5.3 Organizational culture
The final factor is ‘organizational culture’, which is defined as “the elements – symbols, values, meanings, cognitions, myths, stories, and so on, as well as practices, structures, and rules – that characterize the dynamic of an organization” (Dupuis 2007: 1036). An organization’s culture becomes apparent in “informal procedures, norms, routines, and tacit knowledge as found in shared beliefs and stories rather than in documents” (Deverell 2010: 49). According to Deverell (2010: 49), this viewpoint believes that organizations are influenced by “patterns of basic assumptions” based on previous experience and shared by members. As stated earlier, military organizations can be defined as HROs and thus strive to create a ‘culture of reliability’ within the operating organizational unity (Bijlsma et al. 2010: 228). La Porte (1996) argues that a reliability culture unites commitment to mission orientation with ‘safety culture norms’. A safety culture is a form of organizational culture where members repeatedly act and communicate in ways that “serve to construct a particular version of risk, danger and safety” (Pidgeon 1998: 206). This form of culture is characterised by the aim to achieve safety.
The organizational culture of a military organization can influence organizational learning for crisis, because it affects how the organization responds to constraints and incentives provided by civilian decision-makers and senior military leadership as well as external threats (Catignani 2014: 34). Culture plays a vital part in affecting “when and how learning takes place and what is learned” (Nolan 2012: 12). Furthermore, organizational culture exists of a body of shared knowledge created through learning (Bierly & Spender 1995: 643). This means that organizational culture is interconnected with organizational learning (Nolan 2012: 12). If an organization’s culture is concentrated on learning and its structure facilitates people to share knowledge, employees are more likely to feel enabled to learn (Joseph & Dai 2009: 244). Joseph and Dai (2009: 244) argue that an organization can promote an environment that facilitates the learning process through its cultural framework. The authors term this form of organizational culture a ‘learning culture’.
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3. Methodology
This chapter describes the research design and accompanying research methods of the thesis. The theoretical framework presented three factors that are expected to influence organizational learning for crisis. This thesis conducts research on this possible influence by analysing three investigation reports of the DSB that constitute the cases. The first section explains the choice for a multiple-case study design. The second section discusses how the three cases were selected. The third section describes the research methods that are part of the thesis. The fourth section defines and operationalizes the relevant concepts. Finally, the last section discusses the reliability, validity and limitations of the research.
3.1 Research design
The research design is a comparative multiple-case study design and comprises of qualitative research methods. Qualitative case studies are “intensive studies producing rich descriptions of a single phenomenon, event, organisation, or program” (Bowen 2009: 29). This design is chosen because it facilitates the exploration and understanding of complex phenomena. Furthermore, multiple cases are selected as opposed to a single-case study design to strengthen the research (Bryman 2012: 74). The multiple-case study design is ‘holistic’, because it examines one unit of analysis as opposed to an embedded design that studies multiple units of analysis (Yin 2003). The unit of analysis in this thesis is the Dutch MoD. All three cases involve accidents and crises within the MoD between 2009 and 2016. The research design uses an inductive method of reasoning. It started with a literature analysis, which has led to the identification of three factors that are expected to influence organizational learning for crisis at the MoD. The inductive method becomes apparent in the continuous reflection on the theory and empirical cases (Yin 2011: 94). The objective is to contribute to the body of knowledge on organizational learning for crisis at national ministries and HROs on the one side, and the functioning of specifically the Dutch MoD on the other side.
3.2 Case study selection
The selection of cases was based on three criteria. First, there had to be an extensive amount of information available on the cases. Crises and accidents at the MoD are generally researched by internal commissions or by the DSB. Due to limited time the researcher could not gather the same amount of information herself. Since most internal researches are not accessible to
18 outsiders and a number of them are not yet finished, it was chosen to use the investigation reports of the DSB as sources. Moreover, the DSB always includes data of internal MoD researches in their reports, which makes their investigation documents the most comprehensive option. Second, the focus of the DSB researches had to be on the Dutch MoD. The sampling for this research thus includes twelve military accidents and crises that the DSB investigated since January 2003 up and until October 2017.10 Third, since the research idea started because of the recent discussion of crises and accidents within the MoD in the media, the research includes the most recent incident. This is the Mali mortar shell exercise in 2016. For the sake of comparison, this study selected two additional cases that are mentioned in the DSB report on the Mali mortar shell exercise: the Ossendrecht shooting incident and the incident reports 336 Squadron RAF in 2014. Furthermore, a different board at the DSB led the investigations on the MoD that were carried out prior to the three most recent cases. For these reasons, this study limits itself to the three mentioned cases.
The three cases seem different from each other on some areas, but are nonetheless comparable. Although they concern distinct military branches (Air Force and Army) and units, each case is about the Dutch MoD. The specific work of each military branch and unit might differ, but they belong to the same organization. This means that they all deal with similar organizational dynamics such as organizational culture. Moreover, the precise context of each case varies. Whereas one concerns reports of various incidents, the other two focus on specific accidents (conceptualized as crises) during military exercises. Even though the first case does not include a crisis, it does contain information on ‘precursor’ incidents and the pre-crisis management stage. Similar information can be found in the other two cases. In other words, every case involves valuable data on for crisis learning at the MoD. The number of the cases enhances the research. If similar factors influencing pre-crisis learning can be found in three cases, it strengthens the findings and thus the conclusion.
3.3 Data gathering and analysis
The research was carried out through document analysis, which is a systematic procedure for reviewing or evaluating documents (Bowen 2009: 27). The method involves the examination and interpretation of data “to elicit meaning, gain understanding and develop empirical knowledge” (Bowen 2009: 27). Bowen (2009: 31) summarizes seven distinct advantages of
19 document analysis. First, it is an efficient method because it is less time-consuming than other research methods. Document analysis requires data selection instead of data collection. Section, documents are often easily accessible, because they are publicly available. Third, document analysis is less costly than other methods since the data has already been gathered. The researcher only has to analyse the content and quality of the documents. Fourth, documents are ‘unobtrusive’ and ‘non-reactive’, meaning that they are not changed by the research process. The researcher does not have to deal with the issue of ‘reflexivity’, unlike with other qualitative research methods. Reflexivity concerns the awareness that the researcher might contribute to the construction of meanings attached to social interactions and the realisation that the researcher might influence the research. Fifth, since documents do not change because of the research, they are stable and suited for repeated research. Sixth, documents include exact details of events. The presence of exact data forms an advantage for the research. Seventh, documents can provide broad coverage, including a long span of time, multiple events and various settings.
The documents for analysis concern three investigation reports of the DSB on various incidents within the MoD, which constitute the cases for this research. The reports used are ‘Incident reports 336 Squadron Royal Air Force’ (DSB 2014), ‘Ossendrecht shooting incident’ (DSB 2017a) and ‘Mortal accident Mali’ (DSB 2017b). The documents contain many repetitions because they include various summaries. Therefore, only the chapters that contain relevant background information and the actual analyses of the DSB are analysed. All reports are originally written in Dutch, which means that the quoted text parts are translations of the author. The analysis was conducted in four steps. The first step was the selection of thematic categories. The three factors ‘knowledge management’, ‘resistance to change’ and ‘organizational culture’ and ‘organizational learning for crisis’ were used as four distinct categories. Furthermore, the latter category was divided into two sub-categories: ‘formal learning’ and ‘informal learning’. The second step was the definition and operationalization of the four categories and relevant sub-categories. The following section defines and operationalizes the factors in-depth. The third step was the empirical analysis. The research reports were read, whereby parts of the text were thematically coded. This means that paragraphs, sentences or parts thereof were selected as indicators of organizational learning for crisis or as the factors that influence it. During the research, text parts were also marked as indicators if they demonstrated that the factors had a negative influence on the learning process. For example, if the document indicated that relevant knowledge was not properly managed. The fourth step concerned reporting. The reporting was
20 done by systematically quoting the categories found in the texts.11 The number of times that categories were found was counted as well. This was done to provide an indication of the occurrence of each factor. In connection with repetitions in the texts and the prevailing importance of interpretation, the numbers should merely be regarded as supporting the qualitative analysis. The third and fourth step was conducted differently for the category ‘organizational culture’. In addition to searching for text parts that directly indicated ‘organizational culture’, a more interpretative approach was followed as well. An organizational culture includes elements that characterize the dynamic of an organization (Dupuis 2007: 1036). To find out if certain elements occurred often, so that they could be conceptualized as part of the organizations ‘dynamic’, the research reports had to be completely analysed first. After reading a document, repetitive processes could be found which could be connected to the organizational culture. For example, in the first case this concerned the frequent occurrence of trainings. Even though the conduct of a training as such does not directly indicate ‘organizational culture’, the frequent use of trainings indicates a pre-occupation with safety. That points to an HRO and a ‘safety culture’. During the fifth step, the research results were analysed by connecting them to the theoretical framework. Finally, the third, fourth and fifth step were repeated to improve the research results. All the text parts that were coded as one of the categories or sub-categories were put in a table for clarity.12
3.4 Operationalization of variables
The document analysis was conducted by looking for indicators of concepts in the DSB investigation reports. This section defines and operationalizes these concepts. The factors ‘knowledge management’, ‘resistance to change’ and ‘organizational culture’ constitute the independent variables, whereas ‘organizational learning for crisis’ is the dependent variable. The category ‘organizational learning for crisis’ consists out of two sub-categories: ‘formal learning’ and ‘informal learning’. The figure below visualizes the relation between the dependent and independent variables.
11 See Appendix 1. 12 See Appendix 1.
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Figure 1.
For a clear analysis, it is important to delineate the differences between the variables. Nonetheless, it should be kept in mind that they are closely related to each other. The dependent variable ‘organizational learning for crisis’ refers to an actual change that is made within the organization. This can happen because of ‘formal’ or ‘informal’ learning mechanisms. These dependent variables can be influenced by three independent variables. The independent variable ‘knowledge management’ does not equal learning but refers to the question of how the organization and its employees explore and exploit new and current knowledge before any changes to organizational routines are made. The table below defines and operationalizes all the variables used for the analysis.
Concept Definition Indicators Examples
Organizational learning for crisis
“The enhancement of organizational
performance (behaviour) based on newly acquired knowledge (cognition)” (Broekema 2016: 383) before a crisis occurs. The goal is to develop “the ability to deal with crises as they occur” (Smith & Elliott 2007: 524).
The use of modelling, simulation and scenario’s. Military trainings or exercises. The collection, consolidation and distribution of professional and operational feedback, with the outcome of improvements within the organization (formal learning). New or updated doctrines, institutions and practises. Category 4. (dependent variable)
Organizational learning for crisis Sub-category 4.1 Formal learning Sub-category 4.2 Informal learning Category 1. (independent variable) Organizational culture Category 2. (independent variable) Knowledge management Category 3. (independent variable) Resistance to change
22 Individual attention to
personal and collective experience, experience-sharing through
professional and social ‘networks of learning’, with the outcome of improvements within the organization. (informal learning). An employee changes an action after a co-worker suggests an improvement.
Formal learning “The process(es)
generated by institutionalized learning mechanisms” (Bechtel 2017: 22). The collection, consolidation and distribution of professional and operational feedback, with the outcome of improvements within the organization. New or updated doctrines, institutions and practises.
Informal learning “A product of a learning
ethos, rather than the result of an action directly instigated by institutionalized learning mechanisms” (Bechtel 2017: 23). Individual attention to personal and collective experience, experience-sharing through
professional and social ‘networks of learning’, with the outcome of improvements within the organization. An employee changes an action after a co-worker suggests an improvement. Organizational culture “The elements – symbols, values, meanings, cognitions, myths, stories, and so on, as well as practices, structures, and rules – that characterize the dynamic of an
organization” (Dupuis 2007: 1036).
Informal procedures, norms, routines, and tacit knowledge as found in shared beliefs and stories.
The presence of certain norms, like hierarchy,
behaviour, like discipline, or stories, like the aim to achieve safety.
Knowledge management
The collection and transfer of new and current knowledge.
Data gathering through formal data collection systems.
The conduct of interviews or investigations. Data gathering through
informal learning systems. An employee hears new information in his/her social network. The spoken or written
communication of knowledge.
An employee or a written rule informs a co-worker about (new) knowledge.
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Resistance to change “An informal way of
expressing conflict. It is conflict awareness and behaviour which is not anticipated in form and content by the change agency” (Bauer 1991: 184).
Acts of refusal and negative attitudes to change.
An employee does not alter an action after a co-worker suggests an improvement. The enduring presence
of formal and informal structures after it was initiated to change them.
After an
investigation, it is recommended to change a SOP, but the SOP stays the same.
Table 1.
3.5 Reliability, validity and limitations
Validity has many different types, which are not all relevant to each type of research (Bryman 2012; Yin 2003). A general distinction can be made between internal and external validity. Internal validity is about the quality of the match between the observations made by the researcher and the theoretical ideas he or she develops (Bryman 2012: 390). The internal validity of this research is not very strong, because it is difficult to establish causality between the factors and organizational learning for crisis. In qualitative comparative research, it is easier to prove associations than causal inferences (Bryman 2012: 60). The aim of this study is indeed to find to what extent certain factors influence for crisis learning. External validity involves the extent to which the research findings can be generalized across social settings (Bryman 2012: 390). The external validity of this research is limited, because it involves three specific cases within the same organization. It could have been stronger if more cases were selected and if the selection had been completely random (Bryman 2012: 61). However, that was not possible for this research due to time limits. Moreover, not all incidents at the MoD are known to ‘outsiders’. Therefore, a limitation of this research is that it cannot be generalized across all settings of military organizations and HROs. Additionally, the focus on three case studies means that there is less room to examine each individual case in-depth (Bryman 2012: 75). The reliability on documents has limitations as well. First, the documents are not produced for research, which means that they do not provide all the information to answer a research question (Bowen 2009: 31). In addition, the research is only based on three documents. The DSB reports do not include all the formal and informal learning processes that were present at the MoD prior to the crises. Informal learning specifically is hard to research based on documents, because it involves personal processes, which mostly are undocumented. The same can be said about the presence of the independent variables. Interviews would be more appropriate to research personal
24 dynamics such as the presence of an individual learning ethos. Second, the selection of documents involves “biased selectivity” (Yin 1994: 80). The cases for this thesis are partly chosen because comprehensive information on them was available through the research reports of the DSB. As mentioned earlier, this affects the external validity (Bryman 2012: 61). Another limitation involves the bias of the researcher. The coding was carried out by one researcher, whose subjectivity could have influenced the consistency of assigning categories to text parts. This influences the reliability of the study, which refers to whether the results of a study can be repeated (Bryman 2012: 46). Another limitation in this regard is that social contexts change (Bryman 2012: 390). This means that the MoD does not stay the same over time. Additionally, the perspectives on the measured concepts can change and generally differ between researchers. Nonetheless, a multiple case study design has the advantage that the presented evidence is stronger and more reliable than a single case study (Bryman 2012: 74).
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4. Analysis
This chapter contains the analysis of the three cases. Each case will be examined separately, whereby it is analysed to what extent the factors ‘knowledge management’, ‘resistance to change’ and ‘organizational culture’ as well as the processes of ‘formal learning’ and ‘informal learning’ can be found in each DSB investigation report. The occurrence of categories is counted as well as interpreted and ultimately serves to answer the research question. The first three sections each study one case and the last section compares the cases to each other.
4.1 Incident reports 336 Squadron Royal Air Force
This document contains the investigation into the safety situation at the 336 Squadron of the RAF, after several reports were made regarding incidents and (flight) safety shortcomings between 2009 and 2010 (DSB 2014: 7). The 336 Squadron, founded in 2007, is a transport unit and exists of four ‘flights’13 (DSB 2014: 13). The unsafe situations apply to the airbase in Eindhoven (DSB 2014: 9). A former pilot reported the incidents, which mainly concern executed flights for a mission in Afghanistan during that time. After the reports were made in March 2011, several internal investigations started. In April 2013, the reporter stated that these investigations did not convince him that the circumstances had improved. Consequentially, the DSB was asked to carry out research into the safety situation at that time (2014), analysing to what extent the same safety concerns that were present in 2011 still applied (DSB 2014: 9). The DSB analysed 10 reports.
The reported incidents and safety shortcomings are seen as ‘precursor incidents’ from which can be learned before a crisis occurs. They are part of the ‘pre-crisis of management stage’ on which this study focusses (Smith & Elliott 2007: 525). During the analysis the category ‘knowledge management’ was found fifteen times, the category ‘resistance to change’ two times and the category ‘organizational culture’ four times. However, as will be argued in the last sub-section, the frequent conduct of trainings to limit safety incidents indicates a certain dynamic at the 336 Squadron. This dynamic can be conceptualized as a form of organizational culture. Moreover, indicators of ‘organizational learning for crisis’ were encountered eleven times, of which ‘formal learning’ nine and ‘informal learning’ two times.
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Table 2.
4.1.1 Knowledge management
The category ‘knowledge management’ was found fifteen times as a factor that influences organizational learning for crisis. Knowledge management exists of formal and informal gathering and transfer (spoken and written) of knowledge. The category will be analysed accordingly.
Two examples of formal data gathering were found. First, after the reporter came forward with his concerns about safety shortcomings, the Air Force let the Committee of Investigation (CvO) conduct an internal investigation (DSB 2014: 19). The DSB (2014: 39) concludes after its investigation that “none of the reported safety incidents are still present at the moment”. Second, when pilots needed to be deployed to Afghanistan the choice was made to also deploy limited or non-‘combat ready’14 pilots (DSB 2014: 34). This decision was made after an Operational Risk Management (ORM) session. Both examples demonstrate that the Air Force gathered data through formal data collection systems (Catignani 2014: 36). After the internal investigation and ORM session, decisions were made. Moreover, the outcome of the professional feedback led to changes. This points to ‘formal learning’ (Bechtel 2017: 22).
In one instance a lack of formal data gathering was indicated. The DSB (2014: 31) describes that the Towed Paratrooper Retrieval System (TPRS) was not yet certified. A certification involves an investigation to test whether the system works optimal. This is a form of data gathering through formal collection systems (Catignani 2014: 36). Since this data was not collected, no paradrop activities could take place at time of the investigation (DSB 2014: 31).
14 Combat ready refers to the competence to operate a plane in mission area when under threat.
Independent variables Dependent variables
Factor 1: ‘Knowledge management’ Factor 2: ‘Resistance to change’ Factor 3: ‘Organizational culture’
Organizational learning for crisis Formal learning Informal learning
Counted number
27 Without exploring new knowledge, the information cannot be incorporated into organizational routines. This means that organizational learning for crisis was negatively affected.
Five text parts that were marked as indicators of ‘knowledge management’ pointed to unclear or a total lack of spoken transfer of knowledge. The first report states that a commander changed his planned movement and landing and did not communicate this to air traffic control. However, when flight approaches and landings are changed, this has to be authorized (DSB 2014: 20). The third report describes deviations from the standard starting procedures. The commander took off using a different tactic than planned and did not discuss this with his crew (DSB 2014: 22). Reports number four, five and six15 include changes that were made to landing procedures, which were not communicated to the co-pilot (the reporter) (DSB 2014: 24). The seventeenth report includes the lack of standard communication during a flight, which belongs to the required Crew Resource Management (CRM) (DSB 2014: 33). Furthermore, the DSB (2014: 36-37) states that: “The reporter himself came forward late with his reports: he did not report
the (alleged) incidents sooner. It is an obligation to report (suspicions of) unsafe situations directly”. The unclear or total lack of communication indicates a flawed transfer of knowledge,
which means that present knowledge was not exploited. This hinders successful knowledge management and thus the organizational learning process (Catignani 2014: 35).
Two times an employee (the reporter) gathered and communicated information to his commander. In one of these instances, this clear transfer of knowledge led to informal learning. The DSB (2014: 24-25) describes that the reporter told his commander that the landing strip was located on the right side of the plane. Subsequently, “they talked about the situation, after
which the navigation error was corrected” (DSB 2014: 25). This situation demonstrates the
relationship between knowledge creation and learning (Catignani 2014: 36). First, the reporter gathered knowledge on the location of the landing strip and told his commander about this. Second, they discussed the knowledge, whereby they developed a shared understanding about the situation. Third, the commander accepted the information and changed his action. This indicates a successful informal learning process.
Six text fragments concern the flawed transfer of written knowledge. Report number eight and eleven16 describe inaccurate and missing publications for the planning and execution of flights
15 Reports four, five and six are studied as one report in the DSB (2014) investigation. 16 Reports eight and eleven are studies as one report in the DSB (2014) investigation.
28 (DSB 2014: 26). The Operation Manual Air Mobility (OM-A) does not follow the prescribed layout as prescribed in the Military Aviation Requirements for Fixed wing transport, tanker and maritime surveillance operations (MAR-OPS 1). According to the DSB (2014: 26) “amongst
others the chapter 1.2 ‘Organizational facilities and locations’ is missing and as a result the OM-A limits itself to what happens in Eindhoven. The way of operating in mission area is not described.” Similarly, report number 16 includes the missing of essential official
documentation and regulations about dropping parachutists or cargo from an airplane, so-called airdrops (DSB 2014: 30). The DSB (2014: 30) writes that there were official regulations at time of the report, the ‘Regulation Parachuting’. Since 2010, the rules for the armed forces changed to ‘Regulation Military Parachuting’. However, the DSB (2014: 30) reports that “besides the
regulation parachuting for the parachutist there are and were specific regulations. These regulations are available but not ensured conform the MAR-OPS 1”. MAR-OPS 1 Subpart D
1.425 states that the operator should have a procedure for dropping manned and unmanned parachutes. It describes that these procedures should be mentioned in the Operation Manual, Part A paragraph 8.4. It is allowed to reference to a verified document containing an elaboration on the procedures. The OM-A does not follow the prescribed division and paragraph 8.4 is missing. In Tactical Operating Procedures (TOP), chapter five is dedicated to Air Drop Operations, but this document is not verified. Furthermore, references between the OM-A and the TOP are missing (DSB 2014: 31). Another case of unclear written communication involves the description of the required education and experience of pilots to carry out tactical manoeuvres (DSB 2014: 34).
These examples demonstrate that many regulations exist, but are not always documented in the correct way. The prescribed layout of the Operation Manuals is not followed consistently and is for some parts not described. Where it is described, references to the relevant requirements are missing. Furthermore, the DSB (2014: 38) establishes that “the total of rules is insufficiently
insightful”. This unclear documentation indicates a flawed transfer of written knowledge. This
makes it difficult to implement and follow all existing procedures. When knowledge is not clearly communicated, it cannot be successfully exploited, which obstructs organizational learning for crisis (Catignani 2014: 35).
4.1.2 Resistance to change
From the psychological perspective, which conceptualizes ‘resistance to change’ on a personal level, ‘resistance to change’ was found one time. Two examples demonstrate the importance of
29 the willingness of the recipient to process information by the change agent. Report number three concerns deviations from the standard starting procedures. When the commander took off using a different tactic than planned without prior discussion, the co-pilot (the reporter) observed a potential ‘controlled flight into terrain’ situation17 (DSB 2014: 22). He notified the commander about the unsafe situation, but received no reaction. The refusal of the commander to listen to his co-pilot can be conceptualized as a negative attitude to change (Symon 2005: 1642). In the earlier discussed example, where the reporter informed his commander that the landing strip was located on the right side of the plane, the commander demonstrated a positive attitude to change (DSB 2014: 25). When the recipient of information demonstrates a negative attitude towards it, this can act as a barrier to organizational change and thus learning (Alas & Sharifi 2002: 317).
On a structural level, resistance to change can be defined as the enduring presence of structures after it was initiated to change them (Davidson 2010: 11). This occurred with the implementation of the MAR-OPS 1. The DSB (2014: 38) states that “the original term to
implement the MAR-OPS 1 was 1 January 2008. Meanwhile, it is more than six years later and the MAR-OPS 1 are still not completely implemented.” It is unclear why the implementation
was not yet completed. It could be connected to the organizational culture of the RAF and the MoD, since military cultures are generally conservative and resistant to change (Burr 1998: 9). If structural mechanisms, such as the MAR-OPS 1, which functions as the ‘umbrella’ for all regulations, are not changed, organizational learning is hindered (Davidson 2010: 11).
It is important to mention that the DSB investigation (2014: 39) concludes that none of the reported safety shortcomings in 2011 still existed in 2014. This conclusion does not indicate that the 336 Squadron or the RAF was structurally resisting change. Rather, it indicates that the organization learned from the ‘precursor incidents’, which points to organizational learning for crisis (Cooke 2003).
4.1.3 Organizational culture
The category ‘organizational culture’ was found four times in the investigation report. The first text part that indicates a dynamic that points to ‘organizational culture’ is the following quote:
17 A ‘controlled flight into terrain’ is an accident in which the aircraft is flown into the ground or a different
