The Lessons Learned Handbook

List of figures and tables Acknowledgements Preface Chapter 1: Introduction - learning lessons Learning as a basic instinct Learning in organisations Lessons learned systems in organisations How well do they work? The value of learning lessons Chapter 2: Elements of a lesson learning system Lesson learning approaches in the 15th century What is a 'lesson learned'? The steps in learning a lesson Closing the learning loop Trial and error, or trial and success? Survey results Chapter 3: Lessons learned approaches Formal collect systems Informal collect systems Formal connect systems Informal connect systems A blended approach Chapter 4: Principles of lesson identification When to identify lessons? The principles of lesson identification Aiming for the 'quality lesson' Examples of poor lessons Recommendation: Stories and lessons Self-identification of lessons versus lesson identification processes The questioning process - the metaphor of the tree Roles and accountabilities in lesson identification Chapter 5: Processes of lessons identified Post-project reviews or retrospects After action reviews Individual learning interviews Learning histories Evaluations and assessments Incident investigation Chapter 6: Writing down the lessons Each lesson stands alone The lesson needs to be easy to follow and well structured How much context? Who is the audience? Attachments Quality assurance and validation Lessons must lead to action Chapter 7: Taking action Will there always be an action? What sort of actions are needed? How do you decide the action? Who assigns the action? Escalating the action Closing lessons Chapter 8: Process ownership and process update Who owns the processes? Local vs company process owners The role of the process owner Engagement with the learning cycle Lessons workflow Validation and escalation Documenting processes Chapter 9: Ensuring lessons and updated processes are re-applied Broadcasting new lessons and process improvements Process improvements and training Process review as part of operations Chapter 10: Technology to support lesson learning Lesson repositories Knowledge libraries Publish and search technology Tagging Chapter 11: Sharing and seeking the unwritten lessons Communities of practice Peer assist Baton passing Knowledge handover Promoting conversation Chapter 12: The governance of lesson learning A governance framework Make corporate expectations clear Lesson learning systems Monitoring and measurement The supporting organisation Chapter 13: The principles and processes of safety investigations What happened and why? The investigation process The final report Chapter 14: Learning lessons in networks at Mars, Inc Learn from where we are Learn from what we know Learn from the past six months Formalising the learning Summary Chapter 15: Wikis as part of a learning system; a conversation with Peter Kemper Chapter 16: How not to learn lessons Chapter 17: Conclusions Index