Organizational Learning When Things Go Wrong

This document discusses organizational learning from errors and failures. It contrasts the "old view" of errors, which sees systems as reliable and people as unreliable, with the "new view", which sees errors as symptoms of underlying systemic issues. The old view focuses on blame and punishment, while the new view focuses on understanding reasons for errors and learning from them to improve resilience. The document provides examples of how to identify symptoms of the old view, such as retrospective bias, and replace them with approaches of the new view like considering all available information rather than outcomes. It emphasizes learning from failures as an organization rather than punishing individuals, to build a culture where errors can be reported and addressed without obstruction.