How Do People Learn? • • • • • • • Trial and error (Law of Effect) Practice, practice, practice Rote memorization (declarative knowledge) Vicarious learning (role models) Imaginative rehearsal (simulation) “Another name for learning is failure” “Knowledge is what you get just after you need it” How Do Organizations Learn? (D. Kolb et al.) More concrete Doing More abstract Deciding More action Reflecting Connecting More reflection Many Labels For Learning Innovation Org’n Change Knowledge Management Org’n Learning Quality Improvement Training & Development TMI As A Learning Failure • Three Mile Island – ignorant of near misses at other plants – previous similar errors at TMI; no steps taken – engineers’ critique not acted on • Utility President Herman Dieckamp: “To me that is probably one of the most significant learnings of the whole accident [TMI] the degree to which the inadequacies of that experience feedback loop... significantly contributed to making us and the plant vulnerable to this accident” A Learning Failure at NASA • What was learned from Challenger (1986)? – Pressures for production outweighed expertise – Normalization of risk (accepting known problems) – Back to business as usual; “didn’t get it” • What happened with Columbia (2003)? – – – – More production pressure Leadership that tolerated no dissent Lack of independent voice for safety Safety/quality people are promoted: message? (From Columbia Commission report, 2003 and Leveson et al, 2004) Exercises • Jeweler’s Problem: A woman buys a $78 necklace at a jewelry store. She gives the jeweler a check for $100. Because he does not have the $22 change, he goes to another merchant next door. There he exchanges the woman’s check for $100 in cash. He returns and gives the woman the necklace and her change. Later the check bounces and he must repay the other merchant. He originally paid $39 for the necklace. What is his net cash (out-of-pocket) loss? • Horsetrading Problem: A man buys a horse for $5000, and sells it for $6000. He then buys back the same horse for $7000 and sells it for $8000. What is his total profit or loss from these transactions? Corrective Action Process Condition identified Triage Investigation Immediate responses Tracking and trending Solution development Action implementation Effectiveness review Blame The Troops • During an outage, a design modification was installed to replace old electromechanical indicators with new computer-based indicators in a nuclear power plant control room • Operators were trained and told “there is nothing you can do to harm the new system” • A few months later, an operator entered improper keystrokes and the computer system froze • Root causes were traced to operators and designers • Operators were disciplined • No one in engineering is “singularly responsible” Fixes That Fail Slow work; Alienate workers Problems Less flow of information Regulatory attention J. S. Carroll, Ind. Env. Crisis Qtly, 1995, p. 189 Add complexity Write detailed procedures Diagnoses Reduce trust Report requirements; Lower bond rating Discipline workers Resource availability The Capability Trap Performance Working harder Time Æ Performance Repenning & Sterman, Nobody gets credit for fixing problems that never happened. California Management Review, 2001 Working smarter Time Æ Airline Industry Learning • Safety Reporting System developed to allow pilots (and others) to report problems in a confidential way • Move away from “pilot error” to understand work systems, career systems, etc. • Development of Cockpit Resource Management training, now used throughout aviation and increasingly in hospital O.R.s Health Care Frontier • IOM reports document 44,000+ preventable deaths per year; medication errors alone contribute to 7,000 deaths annually • Some mundane problems, e.g., “wrong site” procedures that we know how to fix, e.g., “sign your site”, yet they persist • And many other problems seem more complex, with unknown fixes Strategy That Wouldn’t Travel • For Monday, read the case (Beer, 1996) • What worked in Wichita? Why? • Use the three lenses, Sloan Leadership Model, and other course concepts to analyze what happened in Wichita • For Wednesday, re-read the case • What went wrong in Lubbock? Why? • This is an opportunity to apply what you have learned! • I will be cold-calling both days, so be prepared!