Why Can't We Learn From Our Mistakes: Learn the Lesson - Tell the Story

摘要

Why don't we learn from our mistakes. The lessons from mistakes are not communicated. The lack of communication may result from a visual and/or procedural dcscription of what happencd without ever identifying the lesson to be learned, or from a poorly written 'Lessons Learned'. Readers of a 'Lessons Learned' that does not clearly communicate a lesson probably resent suggestions that they should review 'Lessons Learned' for constructive input to work planning. They may develop a resistance to reviewing 'Lessons Learned' or having their staff review 'Lessons Learned'. 'Lessons Learned' that do not clearly communicate a lesson are likely generated from a less than adequate incident investigation. Incident investigations are needed that 'Learn the Lesson' and then 'Tell the Story' so that the reader gets the point. Resistance to reviewing or using 'Lessons Learned' may result from several sources. If DOE and contractor management and staff were polled, it might be informative to listen to what they have to say about 'Lessons Learned'.