“This Must Never Happen Again” – 3 tips to use in your organisation

We hear this phrase time and time again from our politicians, business leaders and even in our own homes as one of our family members commits some sin or other.  The prompt for this paper was the Chillcott report with the repeated commentary about the lack of planning from many parts of Government regarding provision of equipment, what was to happen when the war was won and considerations about the wider ramifications of removing a Head of State in the Middle East.  That same week we had the Referendum results and yet again it was clear that planning for an Out result had not happened – when will they learn?  The reality is that we know it will happen again the only variables being when and how big.  So what is this about?  Are humans really that dim?

Arthur M. Schneiderman defines organizational learning as: the acquisition, application, and mastery, of new tools and methods that allow more rapid improvement of those processes whose improvement is critical to the success of the organization.

He goes on to explain – “the process view sees the organization as a collection of interconnected processes. In general, these processes are not being executed at their ultimate potential; there are many gaps, even in those core processes that can affect competitive position. Organizations try to close the gaps that are most important from their stakeholders’ perspective. But, the improvement methodology that they use determines the maximum rate at which this can be accomplished. If their improvement process is mature and held constant, than the learning that goes on within the organization can be called “process learning.”

However, what if the organization decides to pursue a new improvement paradigm that has the potential of accelerating their rate of process learning? I call the acquisition, application and mastery of this new capability “organizational learning.” Organizational learning does not in itself lead to any changes in an organization. What it does is enable faster process leaning. So like the incremental improvement/redesign tide that occurs at the process level, the organizational/process learning tide occurs for the entire system of processes. Organizations continuously move between periods when they are learning and periods when they are applying their newly acquired knowledge. If I understand Chris Argyris’ distinction between single- and double-loop learning correctly, then process learning is an example of the former, and organizational learning of the latter as I’ve defined them”

What this tells us is that whilst we may learn new things it does not necessarily change anything organisationally that impacts outcomes e.g. we still fail to plan, we just do it with more knowledge.

Interestingly in the safety world there is an increasing movement that is steering away from lessons learned to lessons identified thus acknowledging the difficulties with actually learning anything to the point it is embedded in the organisational DNA.

There are other elements that impact learning and perhaps safety presents a good model.  Following a serious incident the people directly involved often become evangelical about safety rules etc.  This is fairly predictable – they have felt or seen firsthand the impact of unsafe behaviour.  They have experienced the emotions and impact to families and friends of such an incident and for them the consequences of safety rules, that yesterday were EU nanny state rubbish, today are the right thing to do!

But do not be fooled, even those who watched a colleague being crushed by a heavy machine lift that went wrong; on the following day were seen walking beneath the suspended machine parts, not everyone learned!

Another aspect to this is that when the incident first happened most employees would likely be following all the rules, but over time this would reduce as people became complacent and the first hand knowledge of the incident would be further diluted over time as the workforce changed through retirements, promotions and new starts – this is called the organisational half-life.

The point here being that if people don’t learn directly following a serious incident involving the ultimate consequences on an individual then how do we expect people to learn in business when the consequences are often much removed from them and are not very serious to them?

First, people take in information better when they think about it themselves rather than by being told, so stop doing information cascades that simply tell everyone what is happening and what they should do – they won’t.

Second, think about the consequences – what is in it for them as well as what might happen if they don’t.  At Board level, Directors get very excited about failure to comply (whether that be financial compliance or safety) because for them they are personally liable and could face jail time if things go wrong.  But at the frontline where they are implementing the policies the consequences for them of applying a wrong code or not checking that the fall arrest equipment is current is very little in the immediate future.  Perspective is everything when thinking about the messages sent out.

Third, even if everyone is passionate about wanting to implement the lessons learned, senior management need to ensure the people have the time to learn the new elements to their roles, have the relevant resources, support or training and that this is followed up routinely until it is a habit for all staff.

The third point is the most important and the one usually missed by organisations.  A typical lesson learned is an email to all employees telling them of what happened, the investigation revealed this lesson that we must all learn and that is it.  When was the last time anyone checked up that you had implemented a new policy or ensured that your staff were observing some new safety rule except at audit?  The follow up is not about making people lives a misery; it is about ensuring that the people are doing the new behaviours for long enough that they become a habit, when this state is achieved new people joining the organisation do these behaviours automatically because…..  everyone else is doing them.

So, if you want things to “never happen again” these are some simple steps to follow.