To find what knowledge has been gained about lessons learned in accident investigations, and who may have studied the topic, a google search seemed like a good starting point. For a "lessons learned" search, Google produced around 20 million hits. Using "lessons learned" with accident or investigation produced 2,420,000 hits. That's a lot of lessons learned. Lessons learned process is another term used frequently in connection with these activities; an advanced Google search for "lessons learned process" produced around 300,00 hits in many diverse fields. When we narrow that search even further by looking for accident or investigation related lessons learned process, an advanced search produced 2810 hits. Now if we want to analyze those processes using a system analysis approach, a search for accident or investigation "lessons learned system" produced a slightly more manageable 645 hits, but that still included many hits not related to accident investigations. To try to narrow the search further, "lessons learning system" and accident or incident we entered, resulting in 5 hits with Google, and 5 with Yahoo. -{mostly my works.)
Using another tack, the 2810 and 645 hit lists were scanned to find references to organizations that had lessons learned process. Many do - some of which derive lessons from investigations. When the 645 hits were scanned, the tenor of the references listed observed to be focused on the lessons, rather that the full breadth and depth of the learning process, from the time data from which lessons are developed until changes based on the lessons have produced expected results. A few exceptions were noted: when major accident processes are examined thoroughly, as in a Challenger space shuttle accident investigation or in the Bunsfield tank farm explosions, calls for improvement in lessons learned processes sometimes occur.
Possibly more significantly goals, criteria, metrics, ouutput specifications, quality assurance and other properties of lessons were noteworthy by their ambiguity or absence, with most focusing on step by step actions to process the lessons that were inputed to the system.
How then can we reasonably expect lessons learning systems to be optimized, or even improved. This is what we are exploring. Some progress has been made and reported.
Contributions of criteria or suggestions for lessons learning system improvement - or critiques of some of the ideas are invited.
