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December 10, 2005


Ashley Bowers

To learn from ones mistakes is always important but to celebrate them to me is not!


IMHO, RCA should not be just for near-missed, failure etc. It should be a standard procedure at the end of any project. It we do that it will become part of the process (of any project or happenings) therefore 'blame' would not be the focus of RCA.

Even the most perfect 'project' can be improved.

Harold Jarche

Sounds very much like aviation safety investigations. The aim is to learn, not cast blame.

Shawn Callahan

This post is timely for me Denham. I'm working on a narrative approach to lessons learning at the momemt and coming to the conclusion that the logical-scientific approach of attempting to eek out the causes of a mistake only reinforces defensive reasoning. This in turn masks there real causes.

While I think it is important to answer these questions posed above I think the group needs to revisit the stories which describe what happened. Through the detail generalities emerge and evidence (anecdotal) is available.

I've just finished reading a couple of interesting papers which explore the idea of learning from failure. Both come to the conclusion that it is very difficult to do because of defensive behaviuor. But both papers assume a logical-scietific investigation. You may have seen what I wrote about the narrative vs. logical-scientific (http://www.anecdote.com.au/archives/2005/12/balancing_narra.html).

1. Baumard, P. and W. Starbuck, H., Learning from Failures: Why It Might Not Happen. Long Range Planning, 2005. 38: p. 281-289.

1. Argyris, C., Teaching Smart People How to Learn. Harvard Business Review, 1991. May-June.

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