From TJ Magazine: Why don't we learn from mistakes?
Steve Macaulay and David Buchanan look at why organisations respond badly to mistakes and what L&D can do about it.
Reading time: 4 minutes.
It’s a familiar story. A serious accident occurs, leading to significant repercussions, accompanied by a firestorm of accusations and blame. An investigation is carried out and recommendations are produced, but the recommendations are not properly implemented. And then another similar incident occurs.
This happens in all sectors, public and private – patient harmed in hospital operating theatre; fatal fire in tower block; explosion on an oil platform; product contaminated in a processing plant.
The British railway timetable fiasco of July 2018 is a good example. The botched new timetable caused widespread chaos and furious commuters. Investigations and reports pointed the finger in so many directions it was impossible to make sure that this wouldn’t happen again.
L&D has key roles to play in developing incident analysis skills, promoting the use of systems failure models to complement root cause analysis, and helping investigators to avoid narrow interpretations.
Organisational errors are no longer a minor 'learning from mistakes' issue. Thanks to social media and rolling news channels, more attention is now paid to serious incidents, and public tolerance for their consequences has fallen. A poor response can cause serious corporate reputational damage and cut short senior management careers.
L&D – and HR in general – has a strategic role in ensuring that these incidents are handled effectively.
As L&D professionals well know, everything that happens is a learning opportunity, for individuals and organisations. So why do organisations repeatedly fail to learn from their mistakes? In this article, we offer a threestage approach to handling mistakes, describing how HR and L&D should anticipate and respond to these events.
The stages of the incident lifecycle include crisis management, investigation and change implementation (see table, above right). L&D has an important role to play at each stage, but it is often marginal or missing and L&D should be playing a more significant role in the learning process.
Stage 1: Crisis management
The priority here is rescue and recovery. The task depends on the nature and scale of the incident: treat the injured, extinguish fires, repair equipment. Given these immediate operational demands, it may seem that there is little need for L&D involvement.
However, anyone close to the incident who has been traumatised may need counselling or other support; the survivors often have the best understanding of what happened, and should be encouraged to share that knowledge before it fades. Information lost at this stage may never be recovered.
Those who are later called as witnesses are often guarded in what they say. L&D thus has key roles to play in providing or facilitating survivor counselling and in preliminary knowledge capture with regard to the causes of the incident.
Stage 2: Undertaking investigations
At this state, the priority is to understand what caused the incident. This is often where the process of learning from mistakes starts to go wrong. The first problem concerns the typically frenzied witch hunt, seeking someone to blame and punish. This is a natural emotional response.
For psychologists, however, this is the fundamental attribution error: focusing on the individual and overlooking the conditions in which they were working. Almost all accidents and errors are system failures. We need to look beyond the individual.
To establish causality, investigation teams typically use root cause analysis, which focuses the explanation on a small number of factors. But incidents are usually caused by combinations of factors interacting with each other over time.
Root cause analysis does not always capture these system properties, and does not exploit the potential of new organisational insights which serious incidents provide.
L&D's role in investigations
The membership, skills, remit and methods of the investigation team are important at this stage. L&D has key roles to play in developing incident analysis skills, promoting the use of systems failure models to complement root cause analysis, and helping investigators to avoid narrow interpretations.
L&D must also play a role in minimising the chances of a recurrence. This is another point where the learning process can be derailed, because:
- Investigation teams usually have limited knowledge of change management, and can make impractical proposals.
- Investigation reports often link one fix to each of the root causes which have been identified, overlooking the underlying system problems which need to be addressed – and which are usually more difficult and costlier to tackle.
- The investigation team’s main role is to produce a good report, after which their work is done. Implementing their recommendations will be someone else’s job.
L&D can help to address these issues by contributing to the formation of the investigation team; team membership can be a significant development opportunity for the right person.
Depending on team members’ backgrounds, change management training may also be helpful, covering the importance of communication, selling the benefits, involvement, assessing change readiness and capacity, allocating responsibility for implementation, managing resistance and progress review.
About the authors
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