After the Smoke Clears: Organizational Learning in HROs

A lesson is truly learned when we modify our behavior to reflect what we now know

-Wildland Fire Lessons Learned Center

One hallmark of highly reliable organizations is their ability to focus on their failures. While an obsession with failure may seem contrary to successful operations, it is this preoccupation with errors that ensures that mistakes are pre-empted. When these errors do happen, highly reliable organizations pay attention, examine the causes of mistakes and take steps to ensure that they are contained and avoided in the future.

Many HROs such as the military and fire and police departments use After Action Reviews (AARs) to facilitate this post-crisis learning. AARs enable groups to:

• discuss what happened
• what went well
• what needs improvement
• what lessons can be learned from the experience

Successful organizations learn from mistakes, whether they are large or small. Of course, large, catastrophic errors are easy to detect but successful organizations also pay close attention to potential errors (a misplaced ladder, forgotten safety goggles, a faulty lock, etc.).

The Wildland Fire Lessons Learned Center (LLC) is a website dedicated to “promoting a learning culture to enhance and sustain safe and effective work practices in the wildland fire community.” In an information collection team report, interviews with firefighters revealed potential warning signs that were overlooked:

• “One week before the escape, the people who were continually on the burn repeatedly said ‘It’s just a matter of time until this escapes.’ This thought was not clearly communicated.”
• “I didn’t pick up the extent of the drying trend as reported by field personnel.”
• “In the field we were a little ‘fuzzy’ about the ramifications…”
• “We missed checking the weather radar.”

Successful HROs are especially adept at paying attention to small errors and weak signals of trouble and learning from these experiences. In order to learn from mistakes, organizations need to:

1. Reflect on the context in which learning is applied — analyze problems and issues from the offset
2. Identify strategies that can be put in place to avoid the same mistakes
3. Produce an action plan, allocate tasks and give deadlines
4. Constantly revisit your action plan
5. Share learning with colleagues to ensure they know of the improvements to be made

Of course, all of these steps require great communication both during the AAR and after. Employees need to feel free to communicate potential errors up the corporate ladder and management needs to be open to hearing suggestions. Furthermore, once errors are determined, they need to be communicated throughout the organization to foster learning.

Though small mistakes can be handled by these steps, crises of a larger scale demand a period of heightened awareness where large scale learning can take place. Organizational learning takes three forms: 1) retrospective sensemaking, 2) structural reconsideration, and 3) vicarious learning.

Retrospective sensemaking and structural reconsideration relate to many of the steps considered above. Organizations must be able to look back and make sense of the situation in order to analyze where things went wrong and, at times, organizations may need to be restructured or systems improved so that the mistake will no longer occur. However, an important addition is the notion of vicarious learning.

High reliability organizations need to pay attention to their environment, their competitors and their allies in order to learn from others’ mistakes. It is important to note that when a crisis occurs, it not only provides an opportunity for that organization to learn but other organizations as well.