Samenvatting

Dramatic incidents, such as the 1986 Challenger Disaster, induce the instalment of a Commission to investigate the process that lead to the incident. The Commission attempts to reconstruct the many smaller and larger steps towards the one or several decisions and actions that turned out to be vital – and sometimes fatal. Most Commissions serve a dual purpose; the want to learn lessons and avert similar incidents to occur again, but they are also part of a process to allocate responsibilities and – sometimes – to point the blame. An analysis of Commission-reports reveals two dominant patterns in the narratives Commissions produce. One is relatively simple and identifies the decision or action that caused the incidents; it shows the mistakes that were made, when and by who, The lessons is often to not make the same mistake again. The second pattern is more complicated and produces less ‘crisp’ explanations for the incident. Decisions, actions take place in ambiguous, complex and inherently uncertain contexts. Actors acts amidst such complexity, are subject to all sorts of dynamics and pressures and in the process do things that look awkward or wrong in hindsight. Mistakes happen, not because actors are not smart enough or do the wrong things, but because they are an inherent element of complex decision making. The lesson that follows from that is for organizations that make important decisions under complex conditions to organize checks and balances and look for heterogeneity in their processes. That produces a difficult dilemma, given the ambivalent role of commissions. The second line of reasoning produces much richer lessons for policy, but is very ‘soft’ in casting blame. The first line of reasoning is clearer about responsibility and blame, but oversimplifies the lessons. That draws attention to a crucial – and yet unanswered – question for researchers, practitioners and also the general public; do we see them as platforms for learning or tools for sanctioning?