Learning from Success

or others around them. If they did something wrong, it must have seemed like a good idea at the time, right? Further, we engage in cherry picking of events. Things take on more significance with the benefit of hindsight than they did in real time. We focus on those things because they fit a certain narrative, an explanation for the wrong path taken. But identifying them in this way has little preventative value because they clearly did not seem obvious to workers, managers and/or leaders in real time.

The problem with focusing on what went wrong is that we never get the full story

In addition, people get defensive when you ask them about what went wrong. They either deliberately or subconsciously distort the truth to sound more favourable or to make their mate sound more favourable. While you can improve that somewhat by creating just culture in the workplace, you can't eliminate it altogether. What you get, ultimately, is the version of the truth that people are willing to share with you so you never fully capture the learning from any incident. These things are further exacerbated by the fact that most of our investigation techniques are best designed for story telling rather than analysis. They are based on uncovering the linear timeline of events: "This happened and then that happened." But often the order in which things happen distorts the understanding of why they happened in that conditions may have existed within the system for many years that are important to the incident. This limits our analysis of incidents.

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