Consequence reduction through systematic organizational learning

Baltimore Gas ampersand Electric Company instituted a major trip reduction initiative at Calvert Cliff's nuclear power plant. As part of the effort, the nuclear staff sought the involvement of personnel from outside the Nuclear Energy Division. Participation in this effort resulted in the realization outside the Nuclear Energy Division, as well as inside, that substantial business improvements might be obtained through the systematic use of investigative organizational learning. The purpose of this paper is to discuss the most fundamental aspects of the framework for that systematic organizational learning. Prior to this effort, traditional open-quotes root causeclose quotes efforts were applied by individual work groups to reduce their own impact on service interruptions. These efforts did not result in adequately meaningful insights into significant issues