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LEARNING TEAMS
Learning Teams are a new method and
approach for learning about and from
events (accidents & incidents) and from
normal work.
BUT…
The tool is not nearly as important as the
operating philosophy that underpins it.
THE HOP PRINCIPLES
WORK AS PLANNED vs WORK IN PRACTICE
Work as Planned
Work in Practice
“Workers are Masters of Complex Adaptive Behaviour”
“masters of the blue line”
Conklin & Edwards, 2018
UNDERSTANDING
if we want better answers…
…we have to ask better questions!
A SCENARIO
THE TRADITIONAL
APPROACH
What we would
have found…
• Manual Handling risk
• Rules being broken
• Cardinal rules being broken
• Maintenance not being completed
WHAT IS A LEARNING TEAM?
Learning Teams tell the story:
• As each person saw an event (or
see’s normal work)
• Of complexity
• Of normal variability and
coupling
• Of how work gets done
EDWARDS, 2017
WHAT A LEARNING TEAM IS
NOT
Learning Teams are NOT:
• A traditional investigation
• Worried about collusion
• Focused on the “one true story”
• Focused on the one “root cause?”
• Focused on blame
EDWARDS, 2017
WHO’S ON A
LEARNING
TEAM?
• Coach or facilitator (and co-facilitator)
• Small enough to manage but large enough
to capture the context (i.e. 4 –6ish)
• Those close to the event or issue
• Possibly someone from outside the process
• Support members as needed
• Leadership if needed and invited
THE GOAL OF A LEARNING TEAM….
to learn enough that we realize, given the conditions people face,
the information they hold, the tools and equipment they have and the
pressure they are under…
that we would probably have made the same decision
LEARNING TEAM PROCESS
Determine need for Learning Team
1st Session – Learning Mode only
Provide ‘Soak Time’
2nd Session – Start in Learning Mode
Define defences / build new ones / improve
Test defences!
Tracking actions & criteria for closure
Tell the story
FIRST SESSION – LEARNING MODE
• Insight into the problem
• Understanding the context
• Learning not solving
• Learning IS action
• 1-2 hours maximum per session
FIRST SESSION
• Conditions, not choices
• Inviting dissent and diversity
• Avoiding timelines
• Withholding judgement
What we did
find during the
first session…
• Production Pressure, site was underperforming “Design Capacity”. Forever playing catchup.
• Maintenance was not being completed, there was no PM, understaffing, and the maintenance
team had very restricted access to the line (Production pressure, don’t stop the line)
• Insufficient or wrong equipment
• No elevated platform alongside problem sections of the line
• Isolation fences in the wrong places
• Fences blocking access to the in-feed stopping forklift access
• Rules and Cardinal rules being broken
• Climbing on plant and equipment
• Non-isolation of equipment
A ‘MESSY’ STORY
fear of reporting
weak signals
system strengths
resource constraints
local factors
change in plans
incomplete proceduresunclear signals
production pressure
design shortcomings
poor communication
goal conflict
tradeoffs
adaption
latent conditions
system weaknesses
flawed processes
normal variability
near misses
data
past successes
personal factors
surprises
errors
(Conklin, Edwards, Baker & Howe, 2017)
EVENT
SOAK TIME
• Provides a moment to reframe
• Time for reflection
• Generates a need for a summary and
discussion before next session
SECOND SESSION
• Review & recap previous
session
• Discover additional
information
• Identify key themes
SOLUTIONS
• Solutions or concepts are
created, prototyped, tested and
iterated
• Solution is finalised, produced
and launched
• Experimentation
• Tracking actions (feedback)
OPERATIONAL WISDOM
…is the difference between
fixing the right things the first
time or fixing the wrong things
aggressively and often.
CONKLIN, 2016
OUTCOMES FROM
A LEARNING TEAM
Tangible Outcomes
• Learning and insights
• Corrective actions and improvements
Intangible Outcomes
• Sharing of stories
• Changing the narrative
• Engagement and trust
TAKEAWAYS
Consider:
• Size and complexity of problem
• Learning outcome expectations
• Group size
• Learning environment
• Facilitator / Coach
WHERE
TO USE A
LEARNING
TEAM
• Not for everything (resources!!)
• Based on severity (or potential)
• Post-event (injury / quality / operations)
• Near miss or close call
• Good Catch
• Interesting successes
• High risk operations
• Challenging design problems
• Not for criminal behaviour
YOU
CAN’T
HANDLE
THE
TRUTH!
THE HOP PRINCIPLES
What Are Learning Teams And Why Are They So Effective?

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What Are Learning Teams And Why Are They So Effective?

  • 1.
  • 2. LEARNING TEAMS Learning Teams are a new method and approach for learning about and from events (accidents & incidents) and from normal work. BUT… The tool is not nearly as important as the operating philosophy that underpins it.
  • 4. WORK AS PLANNED vs WORK IN PRACTICE Work as Planned Work in Practice “Workers are Masters of Complex Adaptive Behaviour” “masters of the blue line” Conklin & Edwards, 2018
  • 5. UNDERSTANDING if we want better answers… …we have to ask better questions!
  • 8. What we would have found… • Manual Handling risk • Rules being broken • Cardinal rules being broken • Maintenance not being completed
  • 9. WHAT IS A LEARNING TEAM? Learning Teams tell the story: • As each person saw an event (or see’s normal work) • Of complexity • Of normal variability and coupling • Of how work gets done EDWARDS, 2017
  • 10. WHAT A LEARNING TEAM IS NOT Learning Teams are NOT: • A traditional investigation • Worried about collusion • Focused on the “one true story” • Focused on the one “root cause?” • Focused on blame EDWARDS, 2017
  • 11. WHO’S ON A LEARNING TEAM? • Coach or facilitator (and co-facilitator) • Small enough to manage but large enough to capture the context (i.e. 4 –6ish) • Those close to the event or issue • Possibly someone from outside the process • Support members as needed • Leadership if needed and invited
  • 12. THE GOAL OF A LEARNING TEAM…. to learn enough that we realize, given the conditions people face, the information they hold, the tools and equipment they have and the pressure they are under… that we would probably have made the same decision
  • 13. LEARNING TEAM PROCESS Determine need for Learning Team 1st Session – Learning Mode only Provide ‘Soak Time’ 2nd Session – Start in Learning Mode Define defences / build new ones / improve Test defences! Tracking actions & criteria for closure Tell the story
  • 14. FIRST SESSION – LEARNING MODE • Insight into the problem • Understanding the context • Learning not solving • Learning IS action • 1-2 hours maximum per session
  • 15. FIRST SESSION • Conditions, not choices • Inviting dissent and diversity • Avoiding timelines • Withholding judgement
  • 16. What we did find during the first session… • Production Pressure, site was underperforming “Design Capacity”. Forever playing catchup. • Maintenance was not being completed, there was no PM, understaffing, and the maintenance team had very restricted access to the line (Production pressure, don’t stop the line) • Insufficient or wrong equipment • No elevated platform alongside problem sections of the line • Isolation fences in the wrong places • Fences blocking access to the in-feed stopping forklift access • Rules and Cardinal rules being broken • Climbing on plant and equipment • Non-isolation of equipment
  • 17. A ‘MESSY’ STORY fear of reporting weak signals system strengths resource constraints local factors change in plans incomplete proceduresunclear signals production pressure design shortcomings poor communication goal conflict tradeoffs adaption latent conditions system weaknesses flawed processes normal variability near misses data past successes personal factors surprises errors (Conklin, Edwards, Baker & Howe, 2017) EVENT
  • 18. SOAK TIME • Provides a moment to reframe • Time for reflection • Generates a need for a summary and discussion before next session
  • 19. SECOND SESSION • Review & recap previous session • Discover additional information • Identify key themes
  • 20. SOLUTIONS • Solutions or concepts are created, prototyped, tested and iterated • Solution is finalised, produced and launched • Experimentation • Tracking actions (feedback)
  • 21. OPERATIONAL WISDOM …is the difference between fixing the right things the first time or fixing the wrong things aggressively and often. CONKLIN, 2016
  • 22. OUTCOMES FROM A LEARNING TEAM Tangible Outcomes • Learning and insights • Corrective actions and improvements Intangible Outcomes • Sharing of stories • Changing the narrative • Engagement and trust
  • 23. TAKEAWAYS Consider: • Size and complexity of problem • Learning outcome expectations • Group size • Learning environment • Facilitator / Coach
  • 24. WHERE TO USE A LEARNING TEAM • Not for everything (resources!!) • Based on severity (or potential) • Post-event (injury / quality / operations) • Near miss or close call • Good Catch • Interesting successes • High risk operations • Challenging design problems • Not for criminal behaviour

Editor's Notes

  1. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  2. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  3. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  4. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  5. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  6. Brand new plant (less than 12 months old) New Plant Manager (less than one month onsite) Consistently underperforming design output Site Manager has just completed three days of HOP and Learning Teams training (The picture does not depict the actual site or the actual nature of operations)
  7. Our Usual Approach to a situation like this may include – Observations or an Audit Observations or an Audit would have identified: Cardinal rules being broken Manual handling risk
  8. We would have identified lots of blue line but our response would be to call in non-conformance and advise that they should be on the black line.
  9. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  10. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  11. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  12. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  13. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  14. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  15. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  16. We would have identified lots of blue line but our response would be to call in non-conformance and advise that they should be on the black line.
  17. KEY POINTS: Simple explanations = Pick your root cause The Messy Story = Accidents are emergent properties of a complex system. Attribution of a cause or root cause is a choice not an objective statement of fact. We are more interested in understanding how the various conditions coupled and combined. DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  18. KEY POINTS: At least overnight (if at all possible) Allows time to process learnings Allows time to go look Allows time to study and research Allows the coach time to think of additional questions. DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  19. KEY POINTS: Exploring further in Day 3 DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  20. KEY POINTS: Exploring further in Day 3 DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  21. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  22. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  23. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  24. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  25. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES:
  26. KEY POINTS: DELIVERY: REFERENCES: INDIVIDUAL NOTES: