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Learning from Unintended Outcomes

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Learning from Unintended Outcomes United States Department of Agriculture LEARNING FROM UNINTENDED OUTCOMES FACILITATED LEARNING ANALYSIS & LEARNING REVIEW IMPLEMENTATION GUIDE THE RISK MANAGEMENT COUNCIL IN COOPERATION WITH THE OFFICE OF SAFETY & OCCUPATIONAL HEALTH Updated January 2020 Forest Service Learning from Unintended Outcomes January 2020 ii “Our national pastime of baseball differs from the society that spawned it in one crucial way: The box score of every baseball game, from the Little League to the Major League, consists of three tallies: runs, hits, and errors. Errors are not desirable, of course, but everyone understands that they are unavoidable. Errors are inherent in baseball, as they are in medicine, business, science, law, love, and life. In the final analysis, the test of a nation’s character, and of an individual’s integrity, does not depend on being error free. It depends on what we do after making the error.” Carol Tavris and Elliot Aronson Mistakes Were Made (but not by me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts (Orlando, FL: Harcourt, 2007), p235. “Any safety system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture—an organizational climate in which people are prepared to report their errors . An effective reporting culture depends, in turn, on how the organization handles blame and punishment . What is needed is a just culture . .” J. T. Reason Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate, 1997), p195. This guide is intended for use by any organization wishing to foster organizational learning as the response to unexpected outcomes. “I got behind the safety shelter; then in a little bit, I heard a voice say, Get in This Truck!” 2011, Salt Fire Entrapment and Shelter Deployment FLA. (http://www.wildfirelessons.net/viewdo cument/?DocumentKey=b3897dd4- 9928-4e6a-957a-3964acfae1c6 U.S. Forest Service Photo by Tony DeMasters Learning from Unintended Outcomes January 2020 Iii TABLE OF CONTENTS Part 1 – Background, Purpose and Need: ............................................................................................ 6 Considerations for the Agency Administrator ..................................................................................... 6 A. The Benefits of Learning From Unintended Outcomes .................................................................................... 6 B. Which tool should I use for what just happened? An Expandable Process: From AAR to Learning Review .... 7 C. Critical Considerations for the Agency Administrator .................................................................................... 10 D. Learning product/Review Requirements ....................................................................................................... 11 E. How We Got Here .......................................................................................................................................... 12 F. Learning Beyond Accidents ............................................................................................................................ 12 Part 2 - Essential Principles of the Facilitated Learning Analysis Process ............................................ 14 A. The role of accountability in learning and prevention ................................................................................... 14 B. Administrative Assurance of No Punitive Actions .......................................................................................... 16 Handout A: Understanding The Work Under a Just Culture .............................................................................. 18 Part 3 - Initiating the FLA: Before the FLA Team Arrives .................................................................... 19 A. Priority Agency Administrator Actions ........................................................................................................... 19 B. Forming the FLA Team ................................................................................................................................... 20 C. Clear Mutual Objectives ................................................................................................................................. 24 D. Trust ............................................................................................................................................................... 24 E. Cooperation with Other Investigations .......................................................................................................... 25 F. Recommendations – Reserved for a Learning Review ................................................................................... 26 G. Human Performance Expertise ...................................................................................................................... 26 H. Suggested FLA Report Outlines: Complex and Basic ...................................................................................... 28 Part 4 – The FLA Process .................................................................................................................. 29 A. Setting the Stage ............................................................................................................................................ 29 B. Interviewing ................................................................................................................................................... 30 Handout B: Interview Questions ........................................................................................................................ 32 Handout C: FLA “Watch Outs” ............................................................................................................................ 34 C. The Heart of the FLA Process: The Facilitated Group Dialogue ...................................................................... 36 Principles and Agreements for All Involved in the Facilitation ........................................................................... 36 D. The Group Dialogue Session ........................................................................................................................... 37 Participants ......................................................................................................................................................... 37 Agenda for the Dialogue Session ........................................................................................................................ 37 Suggestions to FLA Facilitator for the Group Dialogue Session .......................................................................... 38 Sand Tables and Google Earth ............................................................................................................................ 40 Handout D: Two Suggestions for Dialogue Focus Questions .............................................................................. 41 E. Event/Accident Reconstruction.......................................................................................................................... 42 F. Final FLA Considerations ................................................................................................................................ 42 G. Terminating A Review .................................................................................................................................... 44 Serious Crimes or Reckless and Willful Disregard for Human Safety ................................................................. 44 Learning product Completion ............................................................................................................................. 46 H. Improving the Process .................................................................................................................................... 46 Part 5 – Additional Steps for a Complex FLA ..................................................................................... 47 A. Process for Conducting the Lessons Learned Analysis ................................................................................... 47 B. The Five How’s – Sensemaking ...................................................................................................................... 48 C. Steps for Lessons Learned Analysis ................................................................................................................ 50 Learning from Unintended Outcomes January 2020 iv Part 6 – Capturing and Sharing the Story .......................................................................................... 51 A. FLA Storytelling .............................................................................................................................................. 51 B. Different Perspectives .................................................................................................................................... 52 C. Storytelling Basics: tips for creative nonfiction storytellers ........................................................................... 53 D. The Readback - Story Validation..................................................................................................................... 55 Handout E: Tips for Facilitated Learning Analysis Storytelling Understanding The Work Under a Just Culture 57 Writing the Story .............................................................................................................................
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