Fig xA Illustration of temperature gradient in

Although the literature on organisational learning has been well established since the seminal work of Cyret and March [7] and [5], the literature in the field of learning from rare events of high severity is largely multi-disciplinary and fragmented [29] and [27]. A reason for its being treated as marginal to the mainstream research has probably been the perception that such a field of research was a statistical outlier [19]. Also, there have been few text books on this TAK-242 topic, other than those of Turner [34] on man-made disasters and Kletz [15] on learning from accidents. The fragmentation of the topic has been reflected in the variety of its names, e.g. Learning from Incidents, Learning from Disasters, Learning from Major Events and Near Misses, and Learning from Crises. Recently, however, there has been a endothermic revival of interest and research activity, the Journal of Safety Science dedicating an issue to learning from events and near-misses [6] and another to learning from accident reports [9], The Journal of Contingencies and Crisis Management running an issue on learning from crises and major accidents [8] and The Journal of Organization Science publishing a special on rare events and organisational learning [19]. Also recently published have been reviews of the literature on learning from incidents, accidents and disasters [21], [22], [20] and [10]. In a recent work by Saleh et al. [30], an excellent analysis of a failure of a defense-in-depth (a concept originated in nuclear industry), was studied and applied to the case of BP Texas refinery accident.