A Learning Culture

I believe that one of the quickest ways to discover the learning culture of an organisation is to examine its health and safety policy. Very quickly, this will separate out for you those organisations with a learning culture from the rest with a blame culture. 

I also believe a blame culture is bad for learning and worse, it is bad for safety.

The airline industry is a good case study here. Their health and safety policies are all based on sustaining a learning culture, and have created probably the safest working environment possible in the circumstances. Construction kills far more people than does aviation.

The culture in the aviation industry says that safety has to be systemic. You are required to share your mistakes, so that you and others can discuss them and put things right. And you will be only be disciplined if you make a mistake and do not report it. 

This is not about being nice – it is about learning. 

In aviation every near miss is recorded and discussed. Because accidents don’t just happen. Accidents are an escalation of one near miss after another until the last one hits. Like swiss cheese when all the holes combine to line up and you can see through. Each near miss was an opportunity to break that escalation pathway, and that is the way to avoid accidents. 

Not surprisingly, human error is a major factor. There are interesting and thoughtful books on this, but one example to consider here relates to team work. 

A passenger plane takes off from an airport in the Midlands and quickly the captain sees a warning light. There is a fire in one of the two engines. Not to worry, it can fly on one engine if needed. They practice this routine regularly. The captain tells the cabin crew team and switches off the engine. Only, there is a wiring fault in the cockpit and the wrong warning light has lit up. He doesn’t know it, but the captain has switched off the good engine, not the one on fire. The cabin crew can see this. They talk about it. Should we tell him? No, he’s busy, he knows what he is doing. But? No. Eventually the captain figured it out, but having just taken off, they were too near the ground and ran out of time. Result: sadly, a crash. Learning for others: you are all a team, not just flight deck pilots behind a door and cabin crew juniors who know their place. You are a team, you all are flying this plane. Every one of you.

From this example we can see the escalation of incidents, where each could have been controlled but wasn’t. 

It is tempting to go to blame here. The aircraft designers should fit wing mirrors so the captain can see the engines. The cabin crew should have taken a vote. The airport control tower people should have seen something. And so on. Lawyers come looking for scalps. Newspaper photographers want a face of shame for tomorrow’s front page. Politicians offer a soundbite. 

But when you speak to the families directly involved in such tragedies, they usually don’t want hollow compensation or a show trial. They want the truth, they want to know it won’t happen again, that in the future another family will not have to face what they have endured.

Heavy stuff. But even for more mundane parts of life, such as the school, the council, the supermarket, we all benefit from a mistakes learning culture. Fewer cases of food poisoning, less money wasted on unsuitable street lights, less time wasted sending people to the wrong place, fewer playground fights, less wasted paper, longer lasting pencils, and so on. Less grammatical errors.

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