5 reasons why organisations don’t learn lessons.
If lesson learning is so simple, why do organisations so often fail to learn the big lessons?
We seem to be able to learn the little lessons, like improving small aspects of projects, but the big lessons seem to be relearned time and time again. Why is this?
Some of the answers to this question are explored in the article “Lessons We Don’t Learn: A Study of the Lessons of Disasters, Why We Repeat Them, and How We Can Learn Them” by Amy Donahue and Robert Tuohy. In this article they look at lessons from some of the major US emergency response exercises, and find that many of them are repeated time and again.
In particular, repeated lessons are found in the areas of
- Failed Communications
- Uncoordinated Leadership
- Weak planning
- Resourcing constraints
- Poor Public relations
- Scoping and scope control
- Lack of motivation to fix the issues. As Donahue and Tuohy explain,
“Individual citizens rarely see their emergency response systems in action. They generally assume the systems will work well when called upon. Yet citizens are confronted every day by other problems they want government to fix – failing schools, blighted communities, and high fuel prices. Politicians tend to respond to these more immediately pressing demands, deferring investments in emergency preparedness until a major event re-awakens public concern. As one incident commander put it, “Change decisions are driven by politics and scrutiny, not rational analysis.”
All of these issues are also seen in commercial organisations. There is a reluctance to make big fixes if it’s not what you are being rewarded for, a reluctance to learn from other parts of the organisation, and difficulties in deciding which actions are valid.
- An ineffective lessons capture and dissemination process. Donahue and Tuohy identify the following points:
“While some (AAR) reports are very comprehensive and useful, lessons reporting processes are, on the whole, ad hoc. There is no universally accepted approach to the development or content of reports… often several reports come out of any given incident… agencies or disciplines write their own without consulting each other. These reports differ and even conflict … there is no independent validation mechanism to establish whether findings and lessons are “right” … concern about attribution and retribution is a severe constraint on candour in lessons reporting … the level of detail required to make a lesson meaningful and actionable is lost … meaning is also diluted by the lack of a common terminology … AARs typically focus on what went wrong, but chiefs want to know what they can do that is right. Reports tend to detail things that didn’t work, without necessarily proposing solutions. … those preparing the reports need to understand not only what happened, but also why it happened and what corrective action would have improved the circumstances. Reports of this depth and quality are relatively rare … many opportunities to learn smaller but valuable lessons are foregone (and) there is no mechanism by which these smaller lessons can be easily reported and widely shared”.
That’s quite a list, and again we can also see these issues in industry as well. Lesson learning crucially needs
- A standard lessons reporting format and structure
- An effective approach to root cause analysis,
- A focus on lesson quality
- Openness and honesty
- A validation process
- Lesson capture at overview level as well as the level of individual teams and sub-projects
- An ineffective lessons dissemination process. Donahue and Tuohy make the following points:
“The value of even well-crafted reports is often undermined because they are not distributed effectively. Most dissemination is informal, and as a result development and adoption of new practices is haphazard. Generally, responders must actively seek reports in order to obtain them. … There is no trusted, accessible facility or institution that provides lessons learned information to first responders broadly, although some disciplines do have lessons repositories. (The Wildland Fire Lessons Learned Center and the Center for Army Lessons Learned are two prominent examples.)”
In fact, the Wildland Fire lessons center and the Center for Army Lessons Learned represent good practice (not just in technology, but in resourcing and role as well) and are examples that industry can learn from. However the issue here is not just dissemination of lessons, but synthesis of knowledge from multiple lessons – something the emergency services generally do not do.
- An ineffective process for embedding change. Donahue and Tuohy address this under the heading of “learning and teaching).
“Most learning and change processes lack a formal, rigorous, systematic methodology. Simplistically, the lesson learning and change process iterates through the following steps: Identify the lesson > recognize the causal process > devise a new operational process > practice the new process > embed/institutionalize and sustain the new process. It is apparent in practice that there are weaknesses at each of these steps….
The emergency response disciplines lack a common operating doctrine…. Agencies tend to consider individual incidents and particular lessons in isolation, rather than as systems or broad patterns of behavior. … Agencies that do get to the point of practicing a new process are lulled into a false sense that they have now corrected the problem. But when another stressful event happens, it turns out this new process is not as firmly embedded as the agency thought … Old habits seem “safer,” even though past experience has shown they do not work.
Follow-up is inadequate … Lessons are not clearly linked to corrective actions, then to training objectives, then to performance metrics, so it is difficult for organizations to notice that they have not really learned until the next incident hits and they get surprised”.
This is the issue of lesson managament, which represents Stage 2 of lesson learning maturity. Many organisations, such as the ones involved in emergency response, are stuck at stage 1. Lesson management involves tracking and supporting lessons through the whole lifecycle, from identification through to validated and embedded change.
There really is little point spending time collecting lessons if these lessons are then not managed through to resolution.
- A lack of dedicated resources. Donahue and Tuohy again –
“Commitment to learning is wasted if resources are not available to support the process. Unfortunately, funds available to sustain corrective action, training, and exercise programs are even leaner than those available for staff and equipment”.
Lesson-learning and lesson management need to be resourced. Roles are needed such as those seen in the US Army and the RCAF, or in Shell, to support the process. Under-resourcing lesson learning is a major reason why lesson learning so often fails.
Donahue and Tuohy have given us some sobering reading, and provided many reasons why lesson learning is not working for Disaster response. Perhaps the underlying causes are the
lack of treating lesson learning as a system, rather than as a product (ie a report with documented lessons), and a lack of treating lesson learning with the urgency and importance that it deserves.
Make no mistake, many commercial organisations are falling into the same pitfalls that Donahue and Tuohy describe.
If learning lessons is important (and it usually is), then it needs proper attention, not lipservice.
2 Comments so far:Shared by: Nick Milton January 15, 2018
Tags: learning from experience, lessons learned