Saturday, June 7, 2008

Lessons Learning Systems

Accident investigation practices that produce "lessons learned" are coming under increasing scrutiny. Issues surfacing as a result of this scrutiny include how to streamline and maximize lessons learned development, documentation, dissemination, accessibility, internalization and feedback. Serious challenges to many aspects of current lessons learned systems are emerging from this scrutiny, including aspects such as the
  • cause-based framework of present lessons learnedsystems
  • orientation of accident investigations relative to lessons learned
  • focus of lessons learned efforts,
  • derivation of lessons learned during accident investigations
  • maximization of the number of lessons learned
  • language and structure of lessons learned documentation,
  • latency in lessons learned cycles,
  • context available with lessons learned,
  • harmonizing of lessons learned data derived from accidents and other mishap investigation with lessons derived from other sources in an organization,
  • data density of lessons learned outputs,
  • breadth of the accessibility of lessons learned,
  • internalization of lessons learned when accessed,
  • monitoring of changes in activities attributable to lessons learned in mishaps,
  • lessons learned life span,
  • lessons learned obsolescence, and
  • strategies for improving lessons learning systems performance
See for a presentation about this topic. And chip in your two cent's worth if you have some useful thoughts.