“We do not learn from experience…we learn from reflecting on experience.” — John Dewey
There are too many celebrities and philosophers to count who have talked about the importance of their mistakes in shaping them. Many seem quite pleased, even proud, of the mistakes they’ve made and their ability to rise from them and go on to success.
That’s great when it happens. But there are many mistakes we don’t learn from, or just as bad, we learn the wrong things from.
Mistakes Alone Are Not Experience
One of the requirements of the Process Safety Management (PSM) standard, 29 CFR 1910.119, is that a process hazard analysis (PHA) “address the identification of any previous incident which had a likely potential for catastrophic consequences in the workplace.” Later in the standard, in the element on incident investigation, it says “the employer shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of highly hazardous chemical in the workplace.”
The key terms in these two requirements are, respectively, “address” and “investigate”. What OSHA is asking us to do is to reflect on experience, our own and others, so that we can learn from it, and then apply that wisdom to reduce the likelihood of a reoccurrence of the incident which did or could have resulted in catastrophic consequences.
The experience alone is not enough to reduce the likelihood of reoccurrence. It is the analysis of that experience—the reflection on that experience—and then doing the right things with it that reduces the likelihood of reoccurrence.
Not Just Our Own Experience
Otto von Bismarck held the idea of learning from one’s own mistakes in contempt. He commented, “Fools say that they learn by experience. I prefer to profit by others experience.” Which is to say, we learn by experience, but it doesn’t have to be our own experience.
There are some mistakes we cannot learn from. Al Franken, comedian and former United States Senator, had this insight:
“Mistakes are a part of being human. Appreciate your mistakes for what they are: precious life lessons that can only be learned the hard way. Unless it’s a fatal mistake, which others can learn from.”
You can’t learn from your own fatal mistake. One of the challenges, in addition to learning from your own mistakes, is to learn from the fatal mistakes of others, rather than insisting on making those mistakes yourself.
We know that we’re supposed to learn from our mistakes, so we don’t repeat them, and yet the same mistakes are made again and again. In the chemical process industries, those mistakes can be fatal.
Why do we repeat our mistakes? Because we’re no different from everyone else. Psychologists note that when we focus solely on our mistakes, that neural pathway is reinforced, so that the mistake becomes easier and easier to repeat. The focus needs to be, not on the mistake, but on the correct approach. The more we think about the correct approach, the more we reinforce doing things correctly.
So, while mistakes, yours or those of others, are the place to start, it does us little good to simply be aware of them. What leads to valuable experience is not the list of mistakes, but the understanding of the correct approaches. The regulatory requirement to “address the identification of any previous incident” is not enough. We must consider the approaches that work to address those incidents.
How Should It Be Done?
There is an old saying: Wisdom comes from experience, experience comes from mistakes, and mistakes come from foolishness, so, all wisdom comes from foolishness. The regulations require us to address our mistakes. To transform mistakes from foolishness to wisdom, however, we must consider must acknowledge them, but more importantly, we must focus on how we will do things differently. Do not be satisfied with a litany of what has been done wrong. Insist that the reflection that transforms experience into learning include reflection on how things should be done.