Machine generated contents note: 1.Introduction - learning lessons -- Learning as a basic instinct -- Learning in organisations -- Lessons learned systems in organisations -- How well do they work? -- The value of learning lessons -- Reference -- 2.Elements of a lesson learning system -- Lesson learning approaches in the 15th century -- What is a `lesson learned'? -- The steps in learning a lesson -- Closing the learning loop -- Trial and error, or trial and success? -- Survey results -- References -- 3.Lessons learned approaches -- Formal collect systems -- Informal collect systems -- Formal connect systems -- Informal connect systems -- A blended approach -- Reference -- 4.Principles of lesson Identification -- When to identify lessons? -- The principles of lesson identification -- Aiming for the `quality lesson' -- Examples of poor lessons -- Stories and lessons -- Self-identification of lessons versus lesson identification processes -- The questioning process - the metaphor of the tree -- Roles and accountabilities in lesson identification -- Reference -- 5.Processes of lessons identified -- Post-project reviews or retrospects -- After action reviews -- Individual learning interviews -- Learning histories -- Evaluations and assessments -- Incident investigation -- 6.Writing down the lessons -- Each lesson stands alone -- The lesson needs to be easy to follow and well structured -- How much context? -- Who is the audience? -- Attachments -- Quality assurance and validation -- Lessons must lead to action -- 7.Taking action -- Will there always be an action? -- What sort of actions are needed? -- How do you decide the action? -- Who assigns the action? -- Escalating the action -- Closing lessons -- 8.Process ownership and process update -- Who owns the processes? -- Local vs company process owners -- The role of the process owner -- Engagement with the learning cycle -- Lessons workflow -- Validation and escalation -- Documenting processes -- 9.Ensuring lessons and updated processes are re-applied -- Broadcasting new lessons and process improvements -- Process improvements and training -- Process review as part of operations -- 10.Technology to support lesson learning -- Lesson repositories -- Knowledge libraries -- Publish and search technology -- Tagging -- References -- 11.Sharing and seeking the unwritten lessons -- Communities of practice -- Peer assist -- Baton passing -- Knowledge handover -- Promoting conversation -- 12.The governance of lesson learning -- A governance framework -- Make corporate expectations clear -- Lesson learning systems -- Monitoring and measurement -- The supporting organisation -- Reference -- 13.The principles and processes of safety Investigations / Johnny Martin -- What happened and why? -- The investigation process -- The final report -- 14.Learning lessons in networks at Mars, Inc / Linda Davies -- Learn from where we are -- Learn from what we know -- Learn from the past six months -- Formalising the learning -- Summary -- 15.Wikis as part of a learning system; a conversation with Peter Kemper -- 16.How not to learn lessons -- 17.Conclusions.
