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