Det institutionelle modsætningsforhold mellem samfundets behov for retsfølelse og behovet for forståelse og læring vedundersøgelse af søulykker

Øssur Jarleivson Hilduberg

Student thesis: Master executive thesis


There were two events in 2017 that gave rise to wonder about how authorities prioritise between the need for meeting society’s sense of justice and the need for understanding and learning from the investigation of accidents. The first event was when the Danish Minister for Industry, Business and Financial Affairs was called to a consultation in 2017 to explain why criminal liability was not placed after workplace accidents. The second event was when medical personnel expressed distrust of the Danish Patient Safety Authority after a number of accident cases where doctors were prosecuted for negligence. In one case, the sense of justice was not met, and in the second case, the authority went too far in its efforts to uphold the law. Apparently, there was a contradiction between learning from the accidents and fulfilling the sense of justice at an institutional level. Therefore, the research questions to be studied was how the abolition of the Danish Division for Accident Investigation (DMA) and the formation of the Danish Maritime Accident Investigation Board (DMAIB) created an institutional conflict between the need for meeting society’s sense of justice and the need for understanding and learning from the investigation of accidents? The research question contained the implicit assumption that the abolition of the DMA and the formation of the DMAIB constituted a critical juncture, which led to the contradiction. The study of the research question was based on theoretical concepts describing the organisational change as a change in governance paradigms; from a bureaucratic governance paradigm to a professionally autonomous governance paradigm. The empirical basis for the study was a qualitative document analysis of marine accident reports from DMA and DMAIB, respectively. The document analysis aimed to demonstrate the change in discourses on accidents that formed the basis for the organisational sensemaking at DMA and DMAIB, respectively. The study of the maritime accident reports showed that there was a consistent difference in the reports that were attributable to the theoretically described governance paradigms. The analysis demonstrated that the change in the governance enabled the development of organisational sensemaking, which paved the way for a change in the understanding of what maritime accidents are and how they should be explained. It was here that the critical juncture arose. The contradiction arises when organisations with their different approaches to governance must accommodate their legitimation needs. The DMA moral legitimation needs consisted of making judgments about right and wrong behaviour. The wrong or actionable behaviour should be punished in accordance with the general legal principles in order to meet the need to uphold society’s sense of justice. At the DMAIB, the moral legitimacy consisted of being able to distinguish between which explanations count as true and rational in the industry. What is considered rational in the maritime industry is understanding and learning that prevents future loss in the form of damage to vessels and equipment and human life. As the DMA no longer exists, the DMAIB’s maritime accident investigation reports are the only legitimated narratives about the causes of marine accidents. Therefore, will the narrative about learning and understanding be the prevailing narrative leaving little room for fulfilment of the sense of justice.

EducationsMaster of Public Governance, (Executive Master Programme) Final Thesis
Publication date2018
Number of pages46
SupervisorsChristian Frankel