Critical assessment of the organisational learning system of the fire service in response to fatal accidents to firemen

摘要

In the Netherlands over the past ten years there have been a number of fatal accidents to firemen during the fighting of fires. According to the national Inspectorate responsible for the investigation of these accidents there appear to be patterns in these deaths indicating that the fire service does not learn effectively enough from them to modify its methods and approaches to prevent reoccurrences. This paper reports the results of an analysis of the learning system in place and how it can be improved. The study was conducted through document analysis, interviews and focus groups. Its aim was to understand the channels which are available for assessing and communicating the learning and the barriers to effective development or use of such channels. It also examined the way in which accidents and learning from them are viewed by different levels of the service, from the operational fire crews up to the officers and directors of the fire service at different levels.