Unrealistic or impractical recommendations

The respondents from the Safety Region Amsterdam-Amstelland made several statements that indicate that the recommendations are impractical and difficult to operationalize. In other words, it is difficult to actually work with them and implement them. One of the problems is that the recommendations are formulated too generally, as proven by the following quotes:

Operations specialist: “Well, you know they [the recommendations] are formulated too

generally. Everyone will agree to that. (…) But how can you operationalize them?”55

Crisis management coordinator: “The moment they [the recommendations] become larger or

more general, or about responsibilities, they become more difficult.”56

Operations specialist: “Look, the Inspectorate makes several recommendations, but those have

a stronger administrative nature than an operational nature. You should have to improve certain aspects within the organization in an operational sense, but then you should also

55 _{“Nou, weet je, ze zijn te algemeen geformuleerd. Daar zal iedereen het mee eens zijn. (…) Maar hoe kan je} het operationaliseren?”

56 _{“Zodra ze wat groter of wat algemener worden, gaan over verantwoordelijkheden, dan worden ze wel} ingewikkeld.”

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transfer those recommendations into recommendations and improvement plans for the

organization. You have to weigh that. That is a completely different trajectory”.57

Interestingly, the last quote shows exactly what has been stated in the literature on accident investigation reports. According to the operations specialist, the recommendations have a stronger administrative, or policy oriented, nature, rather than an operational, or practical, nature. This indicates that also in this case, the gap between policy and practice is not bridged, leaving the recommendations little to avail. The interviewee goes on by giving an example from a previous accident investigation report that was addressed to the Safety Region Amsterdam-Amstelland and written by the same Inspectorate. He subsequently comments on the recommendation to offer an actionable advice, which is one of the recommendations that was not acted upon before.

Operations specialist: “Let me put it this way, I think that they [the Safety Region Amsterdam- Amstelland] are disappointed in the extent to which the reports from the Inspectorate have

helped them. So, if you look at the previous one [Inspectorate’s accident investigation report:

‘Treinbotsing Amsterdam op 21 april 2012. Een onderzoek naar de slachtofferregistratie en de grootschalige geneeskundige hulpverlening’] for Amsterdam about the accident with that

train. It states that you must have a victim registration, well, you know, such a statement lacks any practical insight. The question that follows is how you would do that. And how do you think we are going to offer an actionable advice to people who are planning to call 1-1-2 [emergency

number] when it is not necessary at all? How would you do that? Well, so the Inspectorate can

come up with such a nicely formulated recommendation. But they [Safety Bureau] cannot do

anything with that.”58

Clearly, the interviewee finds some of the recommendations too broad or general, therefore too difficult to operationalize. This is indicated by references to a lack of practical insight and stating that the Safety Region cannot do anything with the recommendation to offer an actionable advice. Furthermore, it is important to note that this quote also refers to a negative experience during a past

57 _{“Het omzetten van, zeg maar, kijk, de Inspectie doet een aantal aanbevelingen, maar die hebben meer,} hebben een sterker bestuurlijk karakter dan een operationeel karakter, in operationele zin zou je een aantal zaken moeten verbeteren in je organisatie, maar dan moet je ook eigenlijk, je moet die aanbevelingen

omzetten in aanbevelingen en verbeterplannen voor een organisatie. Dat moet je afwegen. Dat is een volstrekt ander traject.”

58 _{“Maar, laat ik het zo zeggen, ik denk dat ze wel teleurgesteld zijn in, eh, in de mate waarin, eh , zeg maar, de} rapporten van de Inspectie hun geholpen heeft. Dus als je naar de vorige kijkt van Amsterdam, daar staan, hè, dat gaat over dat ongeval met die trein. Daar staat in, ja maar u moet toch een slachtofferregistratie hebben, nou weet je, dat is ontdaan van elk praktisch inzicht zeg maar, zo’n uitspraak. Hoe dacht je dat te doen, is dan de vraag. Ja, en hoe denk je nou dat we een handelingsperspectief gaan doen bij mensen die van plan zijn 1-1-2 te bellen, terwijl dat helemaal niet nodig is. Hoe wou je dat nou doen? Nou, dus, eh, maar ja, de Inspectie komt dan wel met zo'n mooi geformuleerde aanbeveling. Nou, daar kunnen ze echt geen chocola van bakken.”

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learning process after the Inspectorate published an accident investigation report. As explained before, the interviewees expressed disappointment in the extent to which these reports are effective and what can be learned from them. This statement offers an explanation for this disappointment, as the recommendations are too often of an administrative nature rather than a practical nature. It must be noted that the Inspectorate’s coordinating specialist researcher acknowledged that she could imagine that there is some confusion with regards to how a recommendation should or could be implemented in some cases, as well as confusion about who is responsible. This has been discussed previously in section 4.2.

To end with a positive note, the crisis management operator finds the recommendation with regards to providing for clear procedures and agreements in case of disruption of the reachability and continuity of the emergency control room doable and practical.

Crisis management coordinator: “Everything that is about procedures and coming to

agreements is really doable. (…) We can review our procedures, monitor carefully if we followed

them well, we can sharpen them, all of that is fine. So, that is where they are very practical.”59

Hence, the adoption and implementation of that specific recommendation was not hindered by any impracticality of the recommendation, while one can assume based on the results that the general formulation and impracticality of the recommendation to offer an actionable advice did form a barrier to implement that recommendation.