I recently posted this response to a Knoco post on Closed lessons loops, examples from a lessons database.
Enjoy reading both posts, interested in your views…
Hi Nick, like the post. I agree with your views…My PhD lessons learned research has taken me down the safety lessons learned connection (safety culture, just culture etc). On another well known incident, I recall the review of the BP Deepwater Horizon accident investigation revealed how lessons learned of previous “well control event incidents” and “lines of communication” were not acknowledge or addressed and was a contributing cause to the failure (BP 2010, Deepwater Horizon Accident Investigation Report: Cleveland, C 2011, Macondo: The Gulf Oil Disaster, Encyclopedia of Earth, http://www.eoearth.org/article/Macondo:_The_Gulf_Oil_Disaster?topic=64403).
I understand that NASA uses the BP Deepwater Horizon incident as a lessons learned case study paying particular attention to communication deficiencies around government oversight, disregard of data, testing, changes to process, safety culture and lessons learned from previous incidents (NASA 2011, The Deepwater Horizon Accident: Lessons for NASA, Academy of Program/Project & Engineering Leadership, http://www.nasa.gov/pdf/592629main_BP_Case_Study_29AUG2011_FINAL.pdf).
I would appreciate your views on how high reliability organisations operate and their connection with organisational learning by addressing safety problems. They seem to have a flexible and informed reporting systems with a strong commitment to a safety just culture environment. How do we transfer this approach to safety into operational and project management lessons learned?
Please find attached Jon’s PMIQ Chapter Meeting – Brisbane – 19 June 2013 Presentation and youtube link (http://youtu.be/6cGg7rKCuSE ).
The evening went well with many Q & A’s.
Found another great public available lessons learned site from NASA, this time we have a strong connection with Risk Management…my other passion of interest. Enjoy the search…as we dont want to file them as per the picture. Regards, Stephen
Lessons Learned from a Nuclear Accident (A new addition to the lessons learned available to the general public)
As most of you know, I am always on the look out for public domain lessons learned. While researching for a new journal paper I came across the
Institute of Nuclear Power Operations (INPO). The INPO was created as a result of the Three Mile Island event. The INPO help to identify precursors, disseminate lessons learned and best practices, and generally ensure that every plant operates with the best knowledge available (and also to forestall further regulation). The World Association of Nuclear Operators performs these tasks globally. Although knowledge development and dissemination have been successful overall, problems continue in this industry, which is under continuous scrutiny by regulators and a wary public (Carroll 2004).
Nuclear Energy Institute
INPO Updates Report on Lessons Learned From Fukushima Daiichi Accident
Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station
The lessons learned make an interesting read…..
Looks like to me the SLLCK Model could help?
Doesn’t a new knowledge policy just mean another layer of bureaucracy? Looking forward to the new policy http://go.nasa.gov/15QrjzO
“…Where knowledge is concerned, the primary concern is ensuring that we manage the knowledge resources that enable us to execute the agency’s programs, projects, and missions. Up to now, the focus of NASA’s knowledge policy has been on capturing lessons learned in the Lessons Learned Information Systems (LLIS) database. As I’ve written in the past, there is a rich diversity of knowledge work going on across the agency, from the Shuttle Knowledge Console at JSC to the case studies developed at Goddard Space Flight Center. Our policy needs to reflect the breadth of knowledge management efforts already in place across NASA.
In January, the CKOs and points of contact from the centers, mission directorates, and cross-agency support organizations (such as the NASA Engineering and Safety Center and the NASA Safety Center) got together at the Academy Center for Excellence at Kennedy Space Center to forge a new knowledge policy for NASA. We left the meeting with a working draft that is being internally reviewed and revised. Two weeks after that meeting, the NASA Program Management Council granted us authority to proceed with developing this new knowledge policy. In the months ahead, I will be writing more about what the knowledge policy covers and how it should ultimately help NASA practitioners be able to find the knowledge they need when they need it. Stay tuned”
Sure will be….
Lessons Learned from failures (A new addition to the lessons learned available to the general public).
Government and business need to successfully manage programs and projects, to learn from success and failure, and to capture, disseminate and apply lessons learned (Duffield & Whitty 2012). Lessons from failures are a special class of Lessons Learned.
The term failure is defined as ‘a lack of success in doing or achieving something, especially in relation to a particular activity (Collins 2001); or ‘omission of occurrence or performance, or a failing to perform a duty or expected action’ (Merriam-Webster Online Dictionary 2010).
Often individuals and organisations prefer success over failure due to the rewards brought by success. Even discussions of success are more welcome, and we are motivated by success more than by failures. We keep away from discussing failures because blame is usually accompanied with such a discussion. From the collective point of view, project teams often know they are in trouble, however they take no or minimal effort to resolve errors as owning up to failure may cause shame. So not unexpectedly, we tend to hold close to successful experiences and avoid stories of failure. This favouritism leads to a disparity between success and failure as sources of learning’s. Failures are necessary in the sense that they are essential prerequisites for learning, especially for learning lessons to prevent the mistakes of the past.
As you would know from this blog I keep a list of lessons learned available to the general public. I recently came across a Failure Knowledge Database (FKD) hosted by the Japan Hatamura Institute for the Advancement of Technology (Japan Science and Technology). The work of Dr Yotarou Hatamura makes interesting reading.
Enjoy the lessons 🙂
Image courtesy of Stuart Miles at FreeDigitalPhotos.net
PM Community (Linkedin) Wayne asked the question ‘Most of us know how to conduct Lessons Learned, but how many of us actually have an organizational process for conducting Lessons Learned. I’m looking for some examples of documented processes. It may seem like conducting LL is easy, just like falling off a bike, but in my experience I’ve seen some very effective methods and some that just allow the lessons to be observed and then re-experienced. Or the lesson may be handled through tribal knowledge with no artifact to fall back on. So if you’ve got a documented process that your organization uses and can share it, I’d be very interested in seeing what you’ve got.’
To date 37 responses, all very interesting and continues to suggest that the open public discussions highlight the significance of project management, knowledge management and the lessons learned practice. As you know my research to date supports the premise that the project management lessons learned processes today can largely be considered incomplete and misunderstood.
I am focussed on exploring whether a systemic lessons learned and captured knowledge (SLLCK) model can influence the dissemination and application of project management lessons learned between the project team and the organisation. The study suggests that by reconceptualising lessons learned, the SLLCK model can influence the dissemination and application of project management lessons learned. I look forward to continuing with the study over the next few years and sharing the results with the Linkedin pm communities.
All the best, Stephen
Tired of struggling with lessons learned? Confused about knowledge management? Want to find out how organisations can really learn from projects? What’s the connection between knowledge management and swiss cheese?
Knowledge management practices are notoriously difficult to standardise. Every project, every programme and every organisation is different – and what works in one place can be a disaster in another.
APM Knowledge SIG is holding an event where they will hear two very different case studies: one from Brendan McAndrew of Mouchel and one from Michael Norton of the Local Government Association.
Jon Whitty, senior lecturer in project management at the University of Southern Queensland, Australia, will then present a new way of thinking about how to build organisational knowledge from projects. Through discussion based on the two case studies, you will learn how to apply Jon’s model in different environments. (This is the model on which this pmlessonslearned blog is based on. Jon is my PhD supervsior).
At the end of the afternoon you will have some practical examples of managing knowledge and be able to rethink the way your own organisation could adapt its own knowledge and learning practices to its environment. (I am looking foward to the outcome to hear the SLLCK model feedback from the APM Knowledge SIG event)
This event is aimed at project, programme and portfolio professionals looking to develop their understanding of knowledge management beyond traditional approaches.
Body of Knowledge references
||Information management and reporting
My PhD supervisor Dr Jon Whitty will be presenting ‘Truly reconceptualising project knowledge management’ at a UK APM Project Knowledge Management function on Tuesday 4th December 2012.
What better way to begin 2013 than with a new idea about how projects can enable organisations to learn, and how they can deliver projects better in the future.
Many organisations today are struggling with implementing the somewhat unclear concepts of ‘lessons learned’, ‘knowledge capture’ and ‘knowledge management’. This presentation tackles the problems with these concepts head-on and proposes a new practical conceptual model of building organisational knowledge through projects. What is innovative is that this new model has its roots firmly grounded in naturally evolved networked systems.
The new conceptual model is practical and somewhat intuitive when properly understood. At the end of this session you will be able to immediately reconceptualise how your organisation truly learns through projects and could better adapt to its environment.
Dr Jon Whitty is a Senior Lecturer in Project Management at the University of Southern Queensland, Australia. He leads and develops program and project management research and coordinates a Master of Project Management program. Jon is an expert in the application of evolutionary principles to project management matters. He also contributes to the discussion on complex project management and what project management can learn from philosophy.
He has been a member of editorial boards of project management journals, and regularly reviews research and scholarly articles. He frequently present papers at domestic and international project management conferences, and has written book chapters and published articles that present evolutionary and philosophical approaches to project management.
Many of his talks can be found on his YouTube channel
APM Body of Knowledge reference