Lessons Observed. Lessons Admired. Lessons Learned?
When organizations implement business continuity or continuity of operations programs, it’s important that the organizations plan to learn from experience – experience gained from actual events and from tests and exercises. There are also priceless opportunities to learn from the experience of others. Given all those chances to learn, it’s even more important to learn from each of those experiences only once – the first time!
I was again reminded of the importance of learning from experience when CNN recently published an article on the fatal crash of an Air Force C-130. (As an aero engineer, a graduate of the Navy Test Pilot School – and a practitioner of the skills learned therein – and with thousands of military flight hours in my logbook, I am drawn to aviation articles.) The Air Force accident investigation attributed the crash to a night-vision goggle (NVG) case jammed in front of the control yoke by the pilot during loading operations immediately before the fatal flight. I was immediately reminded of a similar incident reported by the RAF in March of last year. In that case, the pilot had placed his personal camera next to the side stick controller – during flight – and it jammed the controls “hard over,” commanding an abrupt and unusual maneuver. Unlike the fatal C-130 case, the RAF airplane was at altitude and the pilot was able to recover controlled flight in time. The RAF pilot courageously reported the incident and it was published and widely available through Aviation Week and other publications.
A year later, it is obvious that that lesson was not “learned,” and it resulted in the deaths of fourteen people, including three who were in the control facility that the airplane crashed into. Why was a lesson, so recently made very public, not internalized by the C-130’s pilot?
There might be dozens of answers to that question, but the crash of that C-130 was far from the only time that the failure to learn a lesson resulted in an accident or some other failure. It seems to me that lessons derived from problems or outright failures are frequently documented and discussed, but then languishes and fails to become part of the “lore” of the community. This is not a problem unique to the Air Force, or even to the military. It exists throughout every community, organization, business, company, team, group and tribe in the world.
Far too often lessons are documented and then discussed. If sufficiently interesting/compelling, they may be admired for a time, but there is, in the vast majority of cases, no articulated way for that lesson to be integrated into the Knowledge Value Stream (KVS) (tip o’ the hat to Michael Kennedy for introducing me to that term) of the organization. Knowledge (lessons actually learned) is only (perhaps a bit hyperbolic here) internalized when it’s part of the KVS of the organization. If lessons are not intentionally incorporated into the organization’s KVS, they will fade from memory and some pilot will jam his controls and pay for it with his life.
It’s up to organizational leadership to emphasize the KVS if there is one (and create one if there isn’t). There needs to be a person responsible for “owning” and maintaining the KVS. In an Air Force squadron, that would be the Standardization Officer (for airplane- and flight-related knowledge – it might well be someone else for tactical knowledge). That responsible person would take appropriate steps to articulate the lesson-to-be-learned and then keep up the pressure until the knowledge embedded in that lesson becomes an organizational commodity.
Before I close, I want to emphasize that this is not only about aviation – this is about all aspects of running a business. Lessons are observed – or admired – and then forgotten in cyber security, manufacturing, human resources, public relations and a host of other areas every day. As leaders who plan to respond and recover from disruptions to our business, we owe it to our organization and to our people to make sure that we actually learn lessons and don’t simply observe or admire them. Learning those lessons and revising our plans accordingly makes us more effective when disaster strikes.