Difference between revisions of "Lessons learned"
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Because of the large variety of nuclear organizations and of the large variety of events and actions that may occur in them, no unique form of the lessons learned report can be given. | Because of the large variety of nuclear organizations and of the large variety of events and actions that may occur in them, no unique form of the lessons learned report can be given. | ||
| − | However, in all cases it is advisable that the findings | + | However, in all cases it is advisable that the findings are recorded in a written form and inserted in the knowledge base of the organization. |
The reports should contain not only the failures but also the successes of the evaluated action, together with all relevant information available. Also, all opinion of the involved staff members should be recorded and included in the lessons learned report, even if they are partly contradictory. | The reports should contain not only the failures but also the successes of the evaluated action, together with all relevant information available. Also, all opinion of the involved staff members should be recorded and included in the lessons learned report, even if they are partly contradictory. | ||
Revision as of 15:35, 9 March 2016
Contents
Definition
Concise descriptions of knowledge derived from experiences that can be communicated through mechanisms such as storytelling, debriefing etc., or summarized in databases.
Purpose and benefit
Lessons learned from a certain action or event or incident have the benefit to help define an action plan how to improve the action to be more effective and avoid failures or incidents in the future. They are often considered a key component of, and ongoing precursor to, effective risk management.
Description
Lessons learned often reflect on ‘what was done right’, ‘what should be done differently’, and ‘how to improve the process and product to be more effective in the future’. In the nuclear industry, operating experience feedback is an example of an applied lessons learned programme. Usually the lessons learned report is the outcome of the after action review.
Variations
Because of the large variety of nuclear organizations and of the large variety of events and actions that may occur in them, no unique form of the lessons learned report can be given.
However, in all cases it is advisable that the findings are recorded in a written form and inserted in the knowledge base of the organization.
The reports should contain not only the failures but also the successes of the evaluated action, together with all relevant information available. Also, all opinion of the involved staff members should be recorded and included in the lessons learned report, even if they are partly contradictory.
The report should contain also an action plan how to use the lessons learned to improve the performance.
Implementation guidelines
- Get the findings in writing, and record all successes and failures together with all important parameters and circumstances.
- Include all opinion of all involved staff members in the report, even if they seem to contradict. People at different positions may see the same event from different points of view.
- Create also an action plan. The idea is to learn from the successes and failures not only to document them.
- See also the Implementation part of the after action review.
Sucess factors
- Avoid that the team feels that the meeting is about punishment or assigning blame. The management has to develop a reputation for listening openly to input and not punishing people for being honest.
- Make the lessons learned report available to those who might profit from it. This is especially important in the nuclear industry, where the operators of NPPs (and also other nuclear organizations) should learn from each-others operating experiences.
- See also the Success factors part of the after action review.
Common pitfalls
- The lessons learned report, and the after action review meeting is not taken seriously. Either the meeting will not be organized at all or it will not be prepared well.
- The after action review meeting will be organized only at a much later time than the relevant process or event was finished. This leads to a substantial loss of the relevant information in the lessons learned report.
- There is not enough time assigned to the evaluation meeting. Not all aspects could be discussed, and not all opinions could be expressed. Therefore the lessons learned report could be superficial or biased.
- Not every involved member of the team was invited to the after action review meeting. As a result, the final statements could be biased, not every point of view could be included in the final report.
- The after action review meeting has turned into a 'finding someone to blame' session. This only does not help to learn from the lessons learned, but also creates an atmosphere of suspicion and fear inside the organization, which prevents expressing honest opinion in the future.
- The lessons learned are not recorded in written form. Therefore they cannot be included in the knowledge base of the organization, and cannot be communicated to other possibly interested partners.
- No action plan will be designed and included in the lessons learned report, to improve the performance in the future.
- Although lessons learned are written down and stored, but they are not communicated, and they are not made available to possible interested partners or staff members.
- See also the Common pitfalls part of the after action review.
