The intent of lessons learned is to review a particular situation and provide specifics on what to do and not to do the next time. Lessons learned are written within companies to share what went well and what went wrong. How the lessons learned are documented and distributed can affect their success.
In the particular case I’m thinking of an individual was injured while using an electric hand tool. The tool was being used as it was intended, but the job was in an area that was difficult to reach so the user was in a body position that required the user’s arms to be fully extended away from his body. The root cause analysis determined that this awkward position was a cause of the incident.
The manager of this group wrote up the incident report and sent it to all the employees as a lessons learned. It was read during the next safety meeting. There were some specifics about the incident in the write-up, but the message was a general precaution like “be careful when using hand tools.”
There’s a good chance that the manager who wrote the lessons learned on this particular hand tool has no experience with that hand tool. This “lesson learned” is going out to 200 people who use these hand tools. Some of these people were experienced employees who may have used that particular hand tool dozens and dozens of times. How effective is a generic statement like “be careful”?
The tool was appropriate for the job, but how the tool was being used could have been improved. After reviewing the owner’s manual for this tool there were several specific adjustments on the tool that, in this particular case, would have reduced the risk of this incident. The warnings about body position and work surfaces in the manual could have been expanded for the incident.
The people who have experience with this tool - the users - are the ones who should be providing the insight for the lessons learned. It’s the specific details within an incident that make the lessons learned valuable. General statements like “be careful” may only erode relations between those who actually do the work and those who manage it – “those managers just don’t get it.”
The difference is pulling the lessons learned from the people closest to the work rather than pushing the lessons learned to them. This also means having people with specific knowledge and experience with the hand tool, reviewing how the job should have been done. This raises the accountability because it places the responsibility for the proper use of that hand tool with the people who use the hand tool. The people closest to the work - the ones who use the hand tools – taking one extra minute to change body position and change the settings on the tool could prevent the incident from ever occurring. This level of detail and participation provides the full value of lessons learned within an organization.
The lessons learned can be a root cause analysis discussion with all the users of this hand tool. “How should this job have been done? What should the settings have been on the tool? What should we have done to improve body position?” The discussion and potential debate with the users of the hand tools is what refines and defines the most effective way to do that job safely. The most experienced front line users should be explaining to the managers how to use that tool.
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