The Weekly Reflektion 45/2025

There are different perspectives that can be used in incident investigations. A Sequential approach considers the incident as a series of cause-and-effect relationships that end in a failure oraccident. It is essential in determining a credible sequence of events. An Epidemiological approach considers the events as the result of the interaction between risk factors and barriers. Incidents occur when multiple layers of defence fail. The Swiss Cheese model made famous by the work of James Reason is an illustrative example. A Systemic approach considers events as a product of complex, dynamic systems and how the system as a whole allows errors to occur and develop. Often used in modern safety research, for example Safety-II concept promoted by Erik Hollnagel et. al. Another approach that is unfortunately still used is to find a scapegoat somewhere down in the organisation and persecute this person. The main advantage with this approach is that it does not require much effort. The disadvantages should be apparent to anyone that follows our Reflektions.

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During the invasion of Norway, a German attack force sailed up the Oslo Fjord towards the Oscarsborg fort. Warning shots had already been fired towards the German ships from both the Rauøy and Bolærne forts at 23:30 and 23:32 respectively on 8 April 1940. The commander of Oscarsborg, Colonel Birger Eriksen, decided to open fire on unknown vessels at 04:21 on 9 April. He did not fire a warning shot since he considered the unknown vessels had already been warned. The first shots from Oscarsborg hit the flagship, the heavy cruiser “Blücher”, which was later also hit by torpedoes from the hidden torpedo battery. The ship sank at Askholmene around 06.20. The other ships in the task force turned away and retreated towards international waters. The action delayed the German march into Oslo and gave the king, government and parliament time to get away. Eriksen’s decision and firing, carried out with a largely untrained and hastily summoned crew, are considered decisive for the political leadership to avoid German capture. Eriksen was awarded the War Cross with Swords for his actions.

After the war, the events were investigated by the Commission of Inquiry of 1945 and the Military Commission of Inquiry of 1946. Both reviewed the Armed Forces’ dispositions in the days around 9 April. The report from 1946 was submitted in 1950 and published as NOU (Norwegian Official Report) 1979:47. The Commission criticized Eriksen for not firing at the retreating German ships and for the surrender of the Oscarsborg fort, which disregarded an order to hold out as long as possible. Eriksen’s reasoning for not firing on the other vessels was that they had reacted to the warning and turned back. Under international maritime law, Norway’s neutrality had been protected, and further action was not necessary. After the action to sink the Blucher, Oscarsborg fort was attacked by German bombers and was vulnerable to devastation. There were both military and civilian personnel on the Island and reports were already being received of capitulation in other Norwegian cities. Eriksen seemed to have had little choice. It should be noted that no one was killed in Oscarsborg fort that evening. 

The Commission’s work was controversial and there are disputing accounts of how Eriksen was treated in the hearings. One of the main criticisms was that the Commission was more concerned about how individual commanders responded in difficult situations, than on the systemic failures of the Norwegian Government and Authorities, and the lack of preparation from the Norwegian Armed Services. Many commanders, including Eriksen, were treatedunfairly and there was the suspicion of making them the scapegoat for their superiors’ failures.