Lessons Learned Part 3: Initiation and Recognition

This is part 3 of a series of posts on the topic of organizational lessons learned. You might want to read parts one and two first if you haven't already.

How do we find lessons? They can't just spring out of nowhere; there has to be something to initiate them. The U.S. Army's Center for Army Lessons Learned (CALL) argues that in order for there to be a lesson, there must first be an event with a beginning and end. Organizational theorist Karl Weick calls this "bracketing," the act of segmenting our experience into chunks so as to more easily make sense of it. Otherwise life would just be an endless stream of consciousness.

Experience is a hard teacher because she gives the test first, the lesson afterward. -- Vernon Law (Pittsburgh Pirates pitcher)

Because we all do chunking and bracketing naturally, there is a general impression (as the quote above indicates) that lessons occur after the fact -- some event takes place, after which if we're lucky a lesson emerges. But lessons can be methodical as well as emergent. We might decide in advance that we want to learn a lesson and then deliberately construct and initiate an event for that express purpose. Building prototypes, test marketing new products, and conducting experiments are all examples of this.

It is also a common belief that a lesson comes from direct experience, but while this is true in most cases it isn't necessarily a requirement. We can also learn lessons by observing competitors, partners, or others outside our own organization. In addition, lessons can be learned through simulation, and in fact this is where some of our most valuable lessons come from. After all, no one would want to improve airline or nuclear reactor safety by deliberately creating actual disasters to practice on.

Once you have discovered what is happening, you can't pretend not to know; you can't abdicate responsibility. -- P. D. James (British mystery writer)

So we see that events provide the opportunities and raw material for lessons, but a lesson still cannot come into existence until it is recognized. This means that organizations can increase their chances of discovering (and thus learning) lessons by actively looking for them. There are several possible sources and techniques for uncovering lessons within an organization:

• Anything that diverts an organization from "business as usual" is a source of new experiences, and thus new lessons to be learned. These diversions might be negative, such as when attempting to deal with an accident, financial blow, or major quality or public relations problem. But they might also be positive, for example when a company branches out into a new market or develops a new technology.
• Having said that, it is also possible for organizations to also learn from business as usual, but these lessons are usually more difficult to detect because of the very fact that it is business as usual. This means that special techniques such as after action reviews or peer assists might need to be incorporated into standard business processes in order to uncover those lessons. Practices such as these have an added benefit in that when they are done repeatedly, employees will develop more of a constant "learning while doing" mindset, increasing their overall sensitivity to recognizing new lessons.
• Most companies have systems for tracking problems in product development, manufacturing, or customer support. These databases can be mined, either manually or automatically, to identify problems and solutions that can be shared. Simple techniques such as Pareto analysis can be used to identify the lessons that are most common or might have the widest impact.
• Management can direct efforts to deliberately search for lessons. This search can be informal ("Go see what you can learn about this ...") or it can be the formal responsibility of a specific part of the organization. For example, NASA has a team dedicated to seeking out lessons throughout the organization, writing them, and disseminating them.
• Lessons might arise out of the consensus coming from Communities of Practice (CoPs). CoPs exist for the primary purpose of sharing knowledge and best practices, so they are a ready-made environment for uncovering lessons. And the value of CoPs as lesson generators can be enhanced even more by the use of online collaboration tools. If employees are using social business platforms to do their work, lessons that aren't recognized immediately in the moment can still be discovered later because the conversations and debates that led to them have been recorded and saved.
• Finally, lessons can be discovered by the use of counterfactual thinking (thinking of what might have been). But to be useful for learning lessons, that thinking must be self-focused (focused on one's own potential actions rather than those of others) and upward-directed (comparing reality to a better possible alternative). For example, almost every automobile driver has experienced that situation where the car in front of you suddenly stops, nearly resulting in a collision. A driver who is not self-focused might complain "That stupid driver almost made me hit him!" A driver who is self-focused but downward-directed might think "I would have hit that car if I hadn't slammed on the brakes." Neither of these thoughts results in learning. But someone who is self-focused and upward-directed might think "If I had left more distance between my car and that one, I wouldn't have come so close to hitting it."

That exact idea is what is behind the U.S Federal Aviation Administration's Aviation Safety Reporting System. The ASRS is administered by NASA for the FAA and collects "incident reports" from pilots, mechanics, flight crews, and air traffic controllers. They give specific instructions not to report criminal violations or actual accidents, which are handled by law enforcement agencies and the National Transportation Safety Board. The FAA recognizes that analysis of "near misses" can be just as valuable for identifying air safety lessons as the analysis of actual crashes.

Most organizations have a wealth of potentially useful lessons stored in their databases, documents, collaboration platforms, and employees' heads. The trick is embedding "detection devices" such as the ones listed above into business processes and culture so that those lessons can be recognized.

Continue to Part 4: Lesson Capture

References:

• Lloyd Baird & John Henderson: The Knowledge Engine: How to Create Fast Cycles of Knowledge-to-Performance and Performance-to-Knowledge
• John Seely Brown & Paul Duguid: "Organizational Learning and Communities-Of-Practice: Toward a Unified View of Working, Learning, and Innovation"
• Marilyn Darling & Charles Parry: "From Post-Mortem to Living Practice: An In-Depth Study of the Evolution of the After Action Review"
• Federal Aviation Administration: "Aviation Safety Reporting System Program Briefing"
• Kent Greenes: "Peer Assist: Learning Before Doing"
• James March, Lee Sproull, & Michal Tamuz: "Learning from Samples of One or Fewer"
• Danny Miller: "A Preliminary Typology of Organizational Learning: Synthesizing the Literature"
• Michael Morris & Paul Moore: "The Lessons We (Don't) Learn: Counterfactual Thinking and Organizational Accountability after a Close Call"
• Todd Post: "The Impact of Storytelling on NASA and Edutech: How Capturing and Retelling Stories Spreads Know-How"
• Gordon Sullivan & Michael Harper: Hope is Not a Method: What Business Leaders Can Learn from America's Army
• Karl Weick: The Social Psychology of Organizing
• Etienne Wenger, Richard McDermott, & William Snyder: Cultivating Communities of Practice: A Guide to Managing Knowledge