BP Oil Spill, Knowledge Management and HBR

Tom Davenport posted an interesting blog in the HBR site this week, entitled: If Only BP Knew Now What it Knew Then where he asserted a relationship between the BP Oil spill, and the reduction of its knowledge management programme.

It's something which Geoff and I have receive many questions on, so I thought it might be helpful to cross-post our responses to Tom's blog here:~

As the other author of “Learning to Fly”, let me add to what Geoff has written, which I agree wholeheartedly with.

It’s been desperately, desperately sad to see the unnecessary loss of life. Tragic to see the environmental impact. Shocking to see the commercial impact. Disturbing, yet understandable, to see the media, political and public reaction.

Being good at knowledge management doesn’t make you immune from making a poor decision, but being put on a pedestal for long enough can give you vertigo. I’m sure Toyota, another veteran of Knowledge Management would agree. As Larry wrote – all that any of us can do is work to improve the odds. I believe that BP’s knowledge management and organisational learning efforts have diminished in recent years, and what was once an almost instinctive culture of learning and sharing between peers has become diluted. I think Tom’s allowing himself some poetic licence in his use of the word ‘relic’, but I don’t disagree with the thrust of his argument. Like Geoff, I’ve been away from BP for too long to offer an informed view as to how much sharing and learning was going on around its operations at the time of the events in Tom’s post.

Clearly something went very wrong.

Hopefully we will learn the what, why, when, how and who of what went wrong over the coming months or years of review and inquiry. Perhaps we’ll find that there are positive knowledge-sharing and collaboration stories which also emerge, showing how competitors, partners and individuals joined with BP to work to remedy the situation. Possibly we’ll discover will be some Apollo 13 paragraphs within this Challenger story? After the final traces of crude have been dispersed, the food-chain has purged itself of the pollutant effects, the rightful compensation paid and livelihoods restored – what will the legacy of learning be for the oil industry? I really hope that the genuine learning is surfaced and shared, and isn’t drowned out by the noise of the legal machinery.

TS Elliot famously wrote: “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?" Perhaps today he would have added: “Where is the learning we have lost in litigation.”

Now that might make another interesting article, Tom.

Geoff Parcell

I am one of the authors of “Learning to Fly” and I have been watching the response to the oil spill in the Gulf of Mexico with a mixture of anguish, sadness and concern. It is almost 9 years since the first edition of “Learning to Fly” was published, and more than 5 years since I left employment with BP, following a period of secondment to the United Nations AIDS agency UNAIDS. I don’t feel in a position to judge whose fault it was, whether the response was adequate, or whether sharing and learning was adequate within BP. I’ll leave that to others.

However there are three main themes on the topic of knowledge management that seem relevant to this story:

1. What knowledge and information are we basing our views on? 2. What sort of environment has been created for collaborating and learning? 3. How well have the risks been managed?

Let’s deal with these in turn.

1. Most of the information we have to base our views on are directly from the media - television, the internet and the press. My Member of Parliament in the UK, David Heath, recently wrote a press article on the future of political reporting.

“I am very worried about the standards of political and other reporting. If we need new politics, then perhaps we need a new journalism too.

Much that is written in the national newspapers is sloppy and under-researched. A lot of it comes from press releases and chats over lunch rather than looking for facts. As a result, much of it is drivel. On top of that you have a layer of unconcealed prurience masquerading as incisive investigation, concentrating on celebrity and trivia over substance, and the whole edifice looks remarkably shallow.”

I have some sympathy with this point of view. The press has moved from reporting news events to providing instant analysis and answers, assigning blame, searching out the high numbers (of casualties, demonstrators or barrels of oil spilt.) Accuracy is not the aim, finding the highest number someone is prepared to state is. In addition, the internet reinforces extreme views by replication, which has the effect of seeming more convincing even though there is no more information.

At the same time BP is providing its own information - video feeds of the well head, video explanations of each attempt to cap the well and stop the flow. Some think there is a bias to that information.

We make our judgements based on the information provided, coupled with our own knowledge, biases and values.

2. One of the biggest barriers to learning the lessons from mistakes is the litigious society we have created. Learning and sharing takes place in a trusting environment. So many incidents - from train crashes, to fires, to conflict situations, to explosions -are subject to litigation that people are afraid to open their mouths. Even for minor car crashes our insurance companies instruct us not to admit liability even when our instinct is to explain our actions and assumptions to others involved. There are few reports of collaboration for this response. BP did acknowledge cooperation between various government agencies and itself. Other oil companies have provided knowledge, experts, equipment and advice to support. I’d have liked to have seen much more cooperation especially with the US government to fix the problem and clean up first, then learn the lessons, and only then address the issue of who pays and who if any is negligent. What I saw and read was a mix of assigning blame, politicking and maintaining reputation; hardly the environment conducive to listening and learning from each other. What are the chances of really learning the lessons so that we can prevent something like this occurring again?

3. We need to manage the risks and for that we need knowledge. As individuals we rarely avoid risks altogether else we’d never get out of bed. We all handle risks not avoid them. When we assess the risk we judge the probability of occurrence, the impact if it happens and the amount of control of influence we have to mitigate the risk. It does come down to judgement and that judgement comes down to having the relevant knowledge.

Malcolm Gladwell in “Blink” shows examples where only a small amount of knowledge is required to make a decision. People who are risk averse often seek more and more knowledge rather than make a judgement. We need less knowledge than we think to make a decision, rather we need the right balance of knowledge and judgement according to our tolerance to risk. What concerned me was not that BP took risks but the response plan to mitigate the risk did not seem to be operational.

The basic principles of Knowledge Management outlined in “Learning to Fly” are as relevant as ever and are being applied within and between many organizations around the world. It is the application of the techniques that matters and the actions taken once you have the knowledge.

Learning before Igloo-building

With the schools snowbound and closed for a few extra days last month, I persuaded my daughters to help me make an igloo. It’s something I’ve always wanted to do. It took a lot longer than I thought and the pretence that this was “Dad helping them” began to slip after a while as and my co-labourers needed a hot chocolate break or two along the way.   I improvised with Tupperware boxes to make my bricks, learned as I went, and bullied/bribed my girls to hold up the walls when we got to the tricky bits. Getting the final block in the roof was an act of sheer desperation and good fortune.    We made it!  Not quite the classical dome shape, I’ll admit, but it lasted the night before a surprise skylight window appeared the following morning, quickly followed by total collapse.  You would think that after 41 years of waiting for that perfect snow, I would have known exactly how to make an igloo; but I didn’t.There is no shortage of material, videos and step-by-step instructions on the web .  A Google search on “how to build an igloo” yields 673,000 results, including some excellent step-by-step videos on YouTube.  If I’d bothered to look at even the first two of these, then I would have known that the whole thing is built as a self-supporting spiral.  After my first layer of snow bricks, I should have cut a shallow incline up the wall to create the beginning of my spiral; but I didn’t.  No, Google and YouTube didn’t let me downThe fact is, I just wanted to get out there with my brick-making and build.

All traces of the igloo have now melted away, but I’m left reflecting on the way I approached the challenge.  How often in an organizational situation do we get carried away with misplaced self-belief, a little (but not enough) knowledge, a little too much ego and  an eager desire to just roll up our sleeves and get on with it?  How often do we deliver something that looks roughly right, but like my igloo, doesn’t withstand the test of time?

As knowledge professionals, it’s easy to sink time and money into making content more easily accessible, navigable, and searchable.  We can construct elegant wikis, enliven our intranets with RSS and real-time twitter feeds, but none of this will  guarantee a better outcome when people have their “igloo moments”.   Sometimes, it’s not because people lack access to the knowledge or the time to find it.  Rather it’s because they just want to get out there and try it their own way – because it’s something they’ve always wanted to.

So what might have caused me to build my igloo better? Perhaps a friend out there with me in the garden that day, saying – “Hey, I’ve tried this before.  If you want it to last, then need to build it this way...” A challenge for better performance from someone I trusted, and the benefit of their first-hand experience exactly at the moment I needed it.  Now that’s a pretty good vision for a knowledgeable, learning organization.

Finally, just to prove that my jokes are no better than my igloo-building skills...

One Eskimo enviously asks another Eskimo: “Which book did you read to find out how to build such a perfect igloo?” The other Eskimo replies:

“Oh that’s easy; I didn’t have to read it anywhere.  Inuit.”

Chimps, Grapes and the cultural power of social learning

Came across this article on the BBC website today.  Interesting to read the interpretation that power of "social learning" in the chimp community is so strong that  the chimps stopped innovating and adapting, and complied with "what they had learned" - however inappropriate and suboptimal that approach was.

Now we can all smile at the chimps with their sticks and grapes - but I can see some parallels here with how culture develops in organisations, and what we learned once about something which works, left unchallenged becomes a barrier to future adaptation. Which in turn, is why I have such a struggle with the term "best practice".

Reminds me of the old apes, the banana and the water spray story.

Here's the BBC article:

Copycat chimps build their own tools after watching video demonstrations.

During a study, the animals were shown footage of a trained chimp combining two components to construct a tool that enabled it to reach a food reward.

When given the same two components, the chimps made their own tools and used them to drag over a tasty treat.

Reporting in the Royal Society journal Proceedings B, scientists say this demonstrates what a "potent effect" social learning has in the primates.

Elizabeth Price, from the University of St Andrews in Scotland, led the research.

"With video, we can control exactly how much information the animals see, so we can understand exactly how much information they need to work out how to do the task," she explained.

This type of behaviour is very rare in the wild
Elizabeth Price St Andrews University

Dr Price and her colleagues put the chimps into five groups during the test.

One of the groups was shown the whole demonstration - where a chimp was handed a rod and a tube that it slotted together. The demonstrator then used this longer composite tool to retrieve a grape from a platform outside its cage.

The other groups were shown progressively less information - with one group just shown the chimp eating its grape.

The researchers then recreated the set-up for the subjects.

They placed a grape on a platform against the outside of each chimp's cage, and handed the animals a rod and a plastic tube.

"Those chimps that saw the full demonstration learned better how to construct the necessary tool (to reach the food)," Dr Price told BBC News.

"The fact that they can learn how to build a better tool for a particular task is very exciting. This type of behaviour is very rare in the wild, and it's an essential part of human tool use."

Watch and learn

"A handful of the chimps that weren't shown the full demonstration learned how to make the tool on their own," said Dr Price.

Chimp using stick as a tool
Chimpanzees usually modify sticks by stripping them of their leaves

"What was interesting about this group was that, when we presented them with the grape at different distances from the cage, they made the appropriate tool to reach it."

Rather than faithfully copy the demonstration, these animals switched between using the unmodified tube or rod, and using the combined tool, depending on how far away the grape was.

"Those that had been shown the full demonstration, and had socially learned to make the longer tool, continued to make it even when the grape was so close that it was more awkward to use," said Dr Price.

"It could be that social learning is such a strong force for the chimps that they apply a blanket rule of 'go with what you've seen' (rather than work out what's most appropriate for the task)."

The team is now planning to carry out the same test in young children to find out how much they rely on social learning.

What the team still do not know why this type of tool-building is not seen more commonly in the wild.

"We've shown that they're clever enough, so there must be something else at play," said Dr Price.

"It may be that when chimpanzees reach an age at which they are... capable of performing these higher level techniques, they may be too old to have access to sufficiently tolerant demonstrators."

A minor case of Corporate Amnesia. US forgets how to make Trident missiles...

Came across this story via Twitter (@davidgurteen) RT KerrieAnnes Blog, via Slashdot...

I wonder how many other fogbanks we'll look back on in a few years time, as a consequence of the current financial crisis?  Still, I guess all that investment in re-learning and re-inventing will provide the global economy with a much needed boost...

US FORGETS HOW TO MAKE TRIDENT MISSILES.

I was incredulous and had always assumed  that military types save lots of records ... in the last year we had been issued with my father's World War II Australian Army service records. And thinking back to TV shows like Cold Case and documentaries on the 1919 Influenza Pandemic tends to lull you into a belief that the USA has enormous records repositories with nothing thrown away.

The story was released to Slashdot by Hugh Pickens on March 9 2009 and within a day was  relayed across over 500 web pages globally presumably via RSS feeds and blog following.  The situation is astonishing - and indicates the cost of not maintaining good archives ... it was hard to believe - but then more conventional news sites were also running the story, including Fox News on March 9 2009 . Within 3 days the 500 web pages had to grown to over 1500 covering the story. In fact initially the story seemed to be just a beat-up & re-run of a  New Scientist story covered a year earlier in its March 8 2008 issue and the UK's Guardian also on March 6 2008. However those aspects did not seem to feature in the US Congressional Defense FY 2009 Expenditure Hearings transcripts.

Hugh Pickens  wrote "The US and the UK are trying to refurbish the aging W76 warheads that tip Trident missiles to prolong their life and ensure they are safe and reliable but plans have been put on hold because US scientists have forgotten how to manufacture a mysterious but very hazardous component of the warhead codenamed Fogbank.

 'NNSA had lost knowledge of how to manufacture the material because it had kept few records of the process when the material was made in the 1980s, and almost all staff with expertise on production had retired or left the agency,' says the report by a US congressional committee.

Fogbank is thought by some weapons experts to be a foam used between the fission and fusion stages of the thermonuclear bomb on the Trident Missile and US officials say that manufacturing Fogbank requires a solvent cleaning agent which is 'extremely flammable' and 'explosive,' and that the process involves dealing with 'toxic materials' hazardous to workers. '

This is like James Bond destroying his instructions as soon as he has read them,' says John Ainslie, the co-ordinator of the Scottish Campaign for Nuclear Disarmament, adding that 'perhaps the plans for making Fogbank were so secret that no copies were kept.' Thomas D'Agostino, administrator or the US National Nuclear Security Administration, told a congressional committee that the administration was spending 'a lot of money' trying to make 'Fogbank' at Y-12, but 'we're not out of the woods yet.'"

And it might have all seemed like  a conspiracy story by the Anti-Nuclear Fraternity ... however in fact it is all officially reported in a March 2009 US GAO (Government Accountability Office) Report - viz

"At the beginning of the W76 life extension program in 2000, NNSA identified key technical challenges that would potentially cause schedule delays or cost overruns. One of the highest risks was manufacturing Fogbank because it is difficult to manufacture. In addition, NNSA had lost knowledge of how to manufacture the material because it had kept few records of the process when the material was made in the 1980s and almost all staff with expertise on production had retired or left the agency. Finally, NNSA had to build a new facility at the Y-12 plant because the facilities that produced Fogbank ceased operation in the 1990s and had since been dismantled, except for a pilot plant used to produce small quantities of Fogbank for test purposes.

 To address these concerns, NNSA developed a risk management strategy for Fogbank with three key components:

(1) building a new Fogbank production facility early enough to allow time to re-learn the manufacturing process and resolve any problems before starting full production;

(2) using the existing pilot plant to test the Fogbank manufacturing process while the new facility was under construction; and

(3) developing an alternate material that was easier to produce than Fogbank.

However, NNSA failed to effectively implement these three key components. As a result, it had little time to address unexpected technical challenges and no guaranteed source of funding to support risk mitigation activities."

Interestingly, some sort of solution must have been found as one refurbished W76 has just gone back into the stockpile, according National Nuclear Security Administration's February 23 2009 media release

 

Ultimately a new facility was built at the Y-12 National Security Complex near Oak Ridge, Tennessee, to begin production of Fogbank once again, but was delayed by poor planning, cost overruns and a failed effort to find an alternative to Fogbank, and so the project overran by a crucial year costing at least an extra $US69 million  according to the GAO report.

Taking lessons back to school...

I've been thinking recently about "Lessons Learned", and how widely that term is used and abused, both inside and outside KM and Organisational Learning circles.  How often in the press do we see Government departments, Football managers, Chief Police Officers et al utter the immortal words:  "we will be learning the lessons from this..."?

I wonder what this really means.  Is a lesson learned when it is identified by a reflecting practitioner, after a specific experience?  Is it learned when it is codified and made available for others, in specific or abstract form?  Or is a lesson learned when another individual has applied it, and experimented with it?

That was the basis of Kolb's learning cycle...

kolb.jpg
kolb.jpg

...but I'm not sure that I could point to many examples of organisations where this cycle of organizational learning represents the norm.  Not

really.

The

Centre for Wildfire Lessons

puts it nicely: 

"A lesson is truly learned when we modify our behavior to reflect what we now know."

What I do see a lot of is something more like this.

Let's call it "Collison's Ignorance Spiral"

(I hope the name doesn't catch on!).

cis.jpg
cis.jpg

Somehow, the "abstract conceptualisation" bit seems to wear a bit thin - too many motherhood statements in lessons learned reports which fester on electronic shelves.   Now it might be that a deliberate abstract conceptualisation step can be short-circuited completely, through storytelling and the rapid exchanges and collaboration available through social media.  Perhaps abstract conceptualisation is a personal, subconscious step, rather than a clumsy organisationally imposed process. I need to think more about that one. 

But I'm still left with a lingering doubt that

we just aren't very good at designing lessons with a (future) learner in mind

. I've been in a number of lessons learned reviews where the intent of the meeting seems to be catharsis for the team or compliance with the process, rather than learning for the organisation.

So, just for fun - what does a well designed lesson look like in a

school

Let's take a primary school lesson as an example (especially as I have a primary teacher conveniently sitting beside me right now!). I am reliably informed that a well designed lesson will have the following components.

Introduction - explain what you want them to learn; clear objectives. Test past learning, build on the results of past learning. Provide exemplar expectations - what would "good" look like? Be accessible to different learning styles (visual, auditory, kinaesthetic). Be capable of differentiate to multiple levels of capability. Combination of activity-based learning and theoretical-based learning, individual and group. Have a list of accessible resources. Conclude with a  plenary to summarise and test what has  been learned.

How do the lessons in your organisation measure up to that checklist?  Perhaps I should spend more time in the classroom...