Fourth selected lesson about learning from accidents
Learning does not take place systematically after an event
is investigated, whether an incident or even a major accident.
It is only when recommendations are implemented
that results are obtained, and the quality of this process
is mostly related to the type of regulatory regime in place
and its ability to adapt and transform public policies. The
independence of specialised investigative bodies seems
to be a sound design feature for learning as it means they
are not a ‘first degree player’, whether operating high risk
systems or regulating them. However, empirical analysis
also demonstrates that learning depends on the different
combinations of interest groups, government leaders or
media before and after events, with a risk of ‘fantasy
learning’.