Do we take sufficient time and trouble to ask questions to really learn from accidents, failures and near-misses? Root Cause Analysis (RCA) is one approach.
Every time things go wrong there is a huge opportunity to learn, redesign and improve performance. Bill Corcoran suggests we start with these questions:
- What were the most important consequences? Actual, expected, potential?
- What makes this event significant?
- What set them up for it?
- What triggered it?
- What made it as bad as it was?
- What kept it from being a lot worse?
- What should be learned from it?
- What should be done about it?
- What is it about the way business is done that makes events like this inevitable?
- What were the earlier, better, safer, cheaper ways that we could have found the causal factors of this one without having the event?
- What's wrong with this picture, i.e., the news story?
- What do you think were the non-consequential precursors to this Real McCoy?
- Can you think of some negative causes for this one?
- Which accidents in your industry does this remind you of?
- Which related accidents does this remind you of?
To enable the learning, we need an environment where failures are celebrated (as learning opportunities), messengers are not shot, reflection in community is encouraged, there is commitment at all levels to avoid known pitfalls, share experience and learning is supported.
Adopting a reflective practice, is a useful additional regular activity within any community of practice, it helps to surface patterns and anti-patterns that capture group expertise and experience in a common advanced shared language.
I found this volume expensive and useful, (get a copy from your library)