Lessons From Failure

Lessons From Failure

For an organization to thrive and mature it must learn from its mistakes. This is also the main purpose of performing root cause analysis. Earlier in the week I saw a post where the author asked the question, why does management ask to review the JSA after an incident occurs? My initial thought was to learn where the system broke down. As I read the comments I started to realize that for many the answers were akin to how to fix blame to what happened. In my experience unless there was blatant and willful misconduct blame needs to be removed from our thought pattern. What we need to do is to look hard at the event to determine what part of the management system broke down that allowed the incident to occur. We can then apply what we learned so that, organizationally, we reduce the potential of repeating our flawed history.

One of the common root causes that I have witnessed is Management Oversight Less Than Adequate (or some variation). This can be viewed in one of two ways first is to blame the Supervisor for doing a poor job watching the workers but if you look back to my earlier statement on blame I doubt it is very likely that blame is the culprit. Since blame is now out of the equation the second option, becomes more prominent, what barriers were present that reduced the effectiveness of the management oversight? This is where the real value of your investigation lies and where you can create the learning/teaching moment. By peeling back, the layers of the onion you reveal what were the barriers to effectively managing the workforce. Is there a lack of resources, are the supervisors spread too thin, is work being properly authorized, are workers encourage to work independently, the barriers can go on and on.... Knowing what failed permits an organization the opportunity to strengthen those particular weaknesses and then develop a corrective action plan that can be monitored and later assessed for effectiveness.

We all are prone to errors and failure what we do with the lessons that come out of those failures determines whether we grow  organizationally or as George Santayana stated "Those who cannot remember the past are condemned to repeat it."