Learning from Failure

This chapter is about the opportunities and difficulties of organizational learning—before as well as after failures. Learning from failure is about more than picking over the evidence of something gone wrong. Learning is about modifying an organization's basic assumptions and beliefs. It is about identifying, acknowledging and influencing the real sources of operational vulnerability. The path to learning from failure is generally paved with intentions to embrace the new view of human error; to see human error as a symptom of deeper, systemic trouble. Organizations that believe they have to "set an example" by punishing or reprimanding individual operators are not learning from failure. Most organizations aim to learn from failures, either after they have happened or before they are about to happen. Creating a safety culture presents an organization with two problems: an easy one and a hard one.