Listening to the news yesterday morning about the anniversary of the Fukushima disaster I was intrigued to hear the correspondent talk of “Tsunami Stones” so I ‘googled’ them today. Here is one article about them:
Turns out that in many villages in Japan and around Fukushima the inhabitants placed stones inscribed with a message ‘Do not build your homes beyond this point”, because they’d be at risk from tsunami floods. How strange is it that those who heeded the warning were saved from the destruction of the Fukushima floods whereas those who ignored them had their home destroyed (sorry about the heavy dose of irony and sarcasm there). I also remember that at the time it became evident that those designing the plant had considered the impact of tsunami floods but had built the sea wall to a lower level that previously experienced and expected levels. So far I’ve not seen anything which explains why they chose to ignore this data. The cynic in me suggests they may well have risk assessed it and decided that the risk was too small to justify the expense of building such a huge barrier. Perhaps the realist in me says that’s true but it is only conjecture.
However, all this set me thinking about ‘learning organisations’ and made me reflect upon the books by Trevor Kletz. Trevor’s contention is that organisations often do not learn from the past and as such repeat the same mistakes but that if the stories of past incidents are regularly told then the chances of repeat are much reduced or indeed eliminated.
Why did some villages heed the warnings of their ancestors? Why did some villages ignore these warnings? My belief is that those in the safe villages continued to recall why the markers were placed. They probably had a mechanism by which they talked about previous incidents; when new builds were proposed and when the season for tsunamis was near, in other words at pertinent times rather than just after an incident and never again.
I had a discussion of sorts on something similar with a client of ours. They exist in a country where massive electrical storms are very predictable yet they had a fatality due to one man being struck by lightening when up a column during a storm. When the local employees at all levels told me this was an “unavoidable accident” I disagreed. They know when the season for these storms begins and ends, maybe not to the day but certainly to the month. Did they have a tool box talk just before that time? No. Could they done? Yes. Would it have saved the life of the individual? Maybe.
But it’s not just about safety. It also applies to plant changes, to personnel and organisational changes. What ever happens, whether successful or not, the learning needs to be captured, reflected upon and revisited regularly at the right times to ensure that successes are repeated and failures are not. The number of project teams that I have worked with have told me that time invested up front pays back many times later in the project but how many teams are given that luxury? How many teams review previous similar projects before starting their own?
I’d be interested to hear of any examples you have of good learning organisations as they are few and far between.
P.S. Part of my drive for these blogs is to provide learning across all the subscribers. With on-line blogs at least the detail will remain available for people to read and reflect upon, not necessarily in the most organised way. In it’s own way, perhaps this blog is creating a learning organisation amongst us all, I hope so.