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MANAGING BEST PRACTICES: Gaining from experience

April 8, 2006
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Figure 1: Lesson learned process

Source: Report GAO-02-195 “NASA: Better Mechanisms Needed for Sharing Lessons Learned.”



It’s important we learn from experiences, and make corrections or improvements to avoid repeating mishaps or mistakes in the future.

The president and CEO of International Coal emphasized this point this past January when he said the owners and management of Sago Mine “...will report all findings in the hope that lessons learned here may help prevent similar problems at other mines.”

When he announced the release this past February of the government report: Federal Response to Hurricane Katrina: Lessons Learned, President Bush acknowledged that we will learn from the experience and become “better prepared for any challenge of nature.”

Lesson learned process

“Lesson learned” can be defined as “knowledge or understanding gained by (positive or negative) experience.” A formal lesson learned process has existed in government organizations for decades. NASA, for example, has used the process for more than 40 years.

Links to various environmental, health and safety lessons learned government web sites are found at http://www.eh.doe.gov/ll/links.html.

The lesson learned process, as described by the U.S. General Accounting Office, is shown in Figure 1.

Last product

Generally, the lesson learned is the last product in response to a significant event. A formal lesson learned should only be developed after: (1) an event is fully investigated; (2) corrective action plans are developed and implemented for the event; and, (3) audits or assessments demonstrate that corrective actions for the event are effective.

Z-10 guidance

The American National Standard for Occupational Health and Safety Management: ANSI/AIHA Z10-2005 encourages the development of a lesson learned process at element 6.2 “Incident Investigation.” ANSI advises that “lessons learned” from an incident investigation should be fed into the organization’s planning or corrective action process.

Sharing information

The key aspect of the lesson learned process is sharing information. A lesson learned will be of little benefit if it is not disseminated, or readily accessible, to those who may need the information. And the lesson learned may be of little value if it is politicized or sanitized of pertinent facts. Lesson learned should be based on fact-finding, not fault-finding.

For information to be shared, it must first be reported. Element 6.2 in ANSI Z10 further describes that organizations should ensure that all barriers to reporting incidents are removed. Examples of obstacles or barriers (see element 3.2C) include lack of response to employee input or suggestions, reprisals (supervisory and/or peer), or other forms of discrimination.

EHS pro’s role

In terms of health and safety, the EHS pro has two primary roles in the lesson learned process (see Figure 1). One, at the verify stage, you should verify the correctness and applicability of a submitted lesson learned. And two, you should take a leading role in promoting and using completed lessons learned to identify and correct hazards and/or system deficiencies before any injury or illness occurs.

To be effective, the complete lesson learned process will require support and participation from all ranks of management, employees, and, where applicable, contractors. For example, where an organization may have created numerous lesson learned reports, management should designate employee(s) to be accountable for setting up a database to electronically process, store, search, and retrieve lesson learned reports.

Report format

The format for a lesson learned report should fit the needs of each particular organization. NASA’s format is a good benchmark (see actual lesson learned reports from NASA at web link above). NASA’s lesson learned report format is as follows:

1. Lesson learned entry number, date, organization, and submitted by.
2. Subject Heading: (e.g. Chemical Overexposure During Thermal Vacuum Cleaning).
3. Abstract: (short story of the event).
4. Description of Event: (facts).
5. Lesson(s) Learned: (numbered or bulleted points, information briefly stated and to the point).
6. Recommendation(s): (numbered or bulleted points, information briefly stated and to the point).
7. Evidence of Recurrence Control Effectiveness: (audit or assessment data).
8. Documents Related to Lesson: (reference to written procedures).
9. Mission Directorate(s): (organizations/departments where the lesson learned is applicable).
10. Additional Key Phrase(s): (search terms).
11. Approval Info: (date of approval, who approved, organization that approved, and approval phone number).
Lesson learned reports do not need to be lengthy. You’ll note that most of NASA’s lesson learned reports are only about two pages.

Bottom line

Every organization should learn from their significant experiences. A lesson learned process is one way to achieve this objective. When organizations share their lessons learned with others, such as many government agencies do, everyone can benefit. A key element in the success of a lesson learned process is an organizational culture that encourages and values knowledge sharing, and does so in a frank and open manner.

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