I was reading in the book “1411 QI Facts”, ‘London burnt down in 1077, 1087, 1132, 1136, 1203, 1212, 1220 and 1227, as well as 1666’ and it reminded me of the Head of Engineering when he was giving the introductory address to a workshop on managing lessons. He started by asking everyone in attendance to write down the answer to his question, “When did we [he inserted details on a safety incident that had happened in his company]? Was it [he gave them four years to pick from]?”
It was actually a trick question because the incident had occurred in all four of the years he listed. What he wanted to drive home to those in attendance was that as a company they weren’t learning. All they were doing was writing something down and then putting it into a database that nobody was accessing.
He wanted to put in place a methodology similar to;
- Something happened, it might be good or bad
- We write it down and call it a lesson
- For each lesson we assign actions that will embed the learning from the lesson into the artefact's that we use in the company everyday
- We assign those actions to named individuals
- We track those actions until they are closed out
- Once the actions are closed out we know that the learning from the initial experience is now embedded in the organisation
- We archive the lesson as it is no longer needed
Only by having such a methodology would prevent his organisation continuing to repeat ‘lessons lost’ in his opinion.