MANAGING SAFETY PERFORMANCE NEWS

Lessons Learned? Really?

We need to identify why they happened…did not work as they should have, learn the lessons…” 
 
     ~Root Cause Investigation Report
 

In the world of operations, nothing’s ever perfect. Things go awry on a regular basis. When they do, dealing with what goes wrong, that’s your job. Fortunately, most of what goes wrong isn’t that big a deal.  
 
But, every once in a while, the problem is a big deal. Then, there’s an investigation. When the problem is a huge deal – the ones that make headlines – the investigation report goes public. When that happens, people like me get to read the report. 
 
Reading investigation reports is something I’ve been doing for a long time. Investigation reports about a wide array of things that went wrong, involving planes, trains, and automobiles. Ships, subs and space capsules. Nuclear reactors, chemical reactors, storage tanks and pipelines.  As a former manager turned consultant, I’ve also seen thousands of investigations about small problems that never went public. 
 
Better me than you. The ones you read are usually about your operation: those you never want to have to read. For your sake, I hope there are not many.
 
As to the reading, it’s not always easy. There’s jargon – technical and managerial – acronyms, and often a complete lack of report writing skills by the report writers. Their high school English teachers would cringe at what their former students failed to learn.
 
That aside, investigation reports actually make for interesting reading. Just don’t do it at bedtime, unless you suffer from insomnia. An investigation report combines human and technical failure with detective work to explain history.  That’s way better than anything I can find to watch on TV. 
 
Of late, “lessons” seem to be a standard part of the report narrative. “Learn the lessons.” “Share the lessons learned.” It wasn’t always that way. Then some genius came up with the term “lessons learned” and now it’s part of the management vocabulary.
 
Why is that?
 
One possible explanation is that just like people, organizations suffer from learning disabilities. Picture an exasperated leader, dealing with a crew of slow learners. “We missed this one again! What’s wrong with you people? Why can’t you learn? I guess I need to go over this one more time. First, you have to …… and you never ….. Do you understand?”
 
Not likely the case.
 
Maybe it’s that leaders are repeating history. Their personal history. They can’t help but do exactly what was done to them when they were growing up….by their parents. Remember how that went down? Do something that didn’t turn out well, then came the lecture from Mom or Dad: “Well, that’ll teach you a lesson!”
 
I can’t help but think about what tennis player John McEnroe said on that subject, following an embarrassing loss: “I learned a lesson out there today. I’m just not sure what it was.”
 
Lessons learned. No matter how this term of art crept into the working vocabulary of leaders, if you’re going to use the term, you should darn sure know exactly what those words mean in plain English.
 
If you do, I doubt you’ll find yourself using that term very often.

Teach Versus Learn
 
Whoever invented the term “lessons learned” clearly forgot what they learned in fifth grade: the difference between teach and learn. Teachers teach; students learn. 
 
Perhaps the creator never learned that difference in the first place. Their fifth grade teacher would cringe: “If only I could make them learn.”
 
But the teacher can’t. And sometimes the students don’t. It was ever thus.
 
When there’s important new information found in an investigation report, it’s the event that teaches the lesson. If you want to find out whether it’s learned, ask the students. 
 
Better yet, test the students. What did you learn by reading this report?
 
If nothing else, can we please use proper English: it is a “lesson taught” – not learned.
 
What’s in a Lesson?
 
That leads us to the more important matter of this edition: the lesson. Websters defines a lesson as a “piece of instruction.” Like a piano lesson. It’s certainly possible an investigation into some uh-oh might uncover something worthy of instruction. “In the course of our investigation we learned something that you probably didn’t know. Were you aware that…….?”
 
That shocked look on the reader’s face reveals the answer. “I had no idea. Thanks for clueing me in.” That’s a lesson.
 
Honestly now, when was the last time something like that was a product of an investigation in your outfit?
 
Rarely do investigations report findings that are shocking, new and totally unexpected. The causes of failures may be disappointing, disturbing, unwanted, and frustrating, but rarely are they completely unforeseen.
 
In plain English, the causes of failures are “problems” – not “lessons”. Causes are things to be fixed – not learned.
 
Case in point: a recent high profile disaster that cost the company’s CEO his job. If you’re a regular reader, you’ll remember it as the subject of last month’s edition of the News. The only good thing that can be said about what went wrong there was that nobody got hurt. 
 
The investigation report – a public document – described all kinds of fingerprints found on the causes, all of which were left by management. More specifically, the managers; not one manager, but a lot of them. In this failure, the list of proximate causes looked like this:
 

  • Rules weren’t followed
  • The priorities were not the priority
  • Plans weren’t communicated to stakeholders
  • Organization silos kept information bottled up
  • Big issues weren’t escalated

 
No getting around the truth: causes are what they are.  This one’s on the leaders, pure and simple. 
 
Like so many of the failures I’ve read about, had any one of these things been done the way they were supposed to be done – starting with following the rules – the disaster would not have happened. But they weren’t, and it did.
 
Causes like these aren’t lessons: a “piece of instruction.” They’re problems: things that need to be fixed.
 
So, fix them!
 
The Principle of Honest Dialog
 
Nobody likes to fail.  No leader I know likes managing a failure. That’s what keeps us motivated to do the right thing and doing the right thing the right way. But, as important as that motivation is to performance, it won’t drive the error rate to zero. 
 
Which brings us right back to where we started: nothing’s perfect. Dealing with problems is a part of every leader’s job. 
 
So, how do you deal with failure? Particularly a big failure, of the type that has your followers’ fingerprints all over it?
 
It’s now common practice for leaders in the aftermath of a failure to point the finger in the direction of culture, system, or process. “This is a management system failure.” Back in the day, it used to be blamed on “Them.” Now it’s “Those.” 
 
I once heard a firsthand report from a leader: “I toured every floor of our headquarters building and could not find the office where “Them” worked.” Now it’s “those” things, for which nobody is responsible. How convenient. 
 
Truth to tell, I suspect the creator of “lessons learned” was looking for a clever way to deflect criticism and scrutiny away from individuals. Individuals who happened to be followers of that leader.  It worked so well that everyone jumped on the bandwagon.
 
Everyone being management and leadership. 
 
My advice to you: don’t. Don’t use the term and don’t think that way.
 
First, because using the term “lessons learned” won’t earn you a passing grade in English. 
 
Second, because in the long term, glossing over the truth about failure makes it easier to avoid dealing with problems that need to be fixed.  In matters of safety, not fixing what needs to be fixed is not doing anyone a favor.
 
Since you know all that, I daresay this edition of the News is not a lesson. More like a reminder of the Principle of Honest Dialog: when it comes to safety, leaders and followers owe it to each other to tell the truth.
 
Paul Balmert
October 2020

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