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The Learning Review -- Looking up the River

Posted by Ivan Pupulidy on Thursday January 19th, 2017

A small village on the shore of a mighty river was home to a tribe of caring people. They looked to the river for life and the river returned many gifts. There was one thing that troubled the people of the village. Every so often a person would be found floating in the river having fallen in upstream. Sometimes the river carried people who were alive and who called out for help. The villagers began to mount rescue efforts and sometimes they were successful. The leaders of the village began to invest in ways to improve recovery efforts. Soon a profession arose in the village that was dedicated to river safety and more and more people were saved as they drifted by. Despite these efforts, some people slipped by only to drown within sight of the villagers. More time and resources were dedicated to the problem, and infrastructure was built to track the number of saves and the number of misses. Technical progress was made that improved the success rates and the trends were posted so all the villagers could see the improvement. At first, the statistics made the people of village happy; however, after at time, the success rate began to plateau.

Scratching their heads and looking directly at the problem, the villagers could not find a way to improve beyond what they had done. Then a new comer to the village, who had watched what was going on and understood the history, asked a simple question, “Why don't you go upstream and explore why so many people are falling into the river?”

For decades we have acted like the villagers, seeing the problem and looking for solutions where only mitigations could be found. We have done this with accident investigation and we have created a robust system of detecting holes in our Swiss cheese and plugging them. In my organization, it seems, we have reached a point of diminishing return and our accident rates have gone largely unchanged. We have gone up stream, thanks to the work of Sidney Dekker, Edgar Schein, Karl Weick and Reuben McDaniel (to name a few). These trail blazers have opened a path that asks us to explore. To move away from the actor and to understand actions in the context of the organization, culture, goal conflicts and environmental conditions. This has moved us to understand the importance of the network of influences that surround any human activity and to begin to explore what is happening up river – a shift in focus from investigating, to learning from events.

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Ivan Pupulidy applies dynamic perspectives to complex systems and high-risk environments, such as wildland firefighting, aviation, military and medicine. His approach to human factors includes the social aspects of human interaction and sensemaking, which are essential components of a learning organization. As a U.S. Forest Service Director, Ivan replaced the traditional accident investigation model with the Learning Review, which embraces complex events by looking at conditions and networks of influence; this approach helps organizations develop learning and cultural change.  

Ivan’s ability to integrate academic research with real world application comes from his varied life experiences, which have included work as a mine geologist, exploration geophysicist, and a U.S. Coast Guard pilot for rescue and law enforcement missions. Ivan served in the U.S. Air Guard and Air Force Reserves, where he flew the C-130 Hercules, including missions as a MAFFS tanker pilot on wildland fires. He also served on active military operations for combat and humanitarian support in Iraq, Afghanistan and Central Africa.

Ivan earned a Master’s of Science degree in Human Factors and Systems Safety at Lund University, Sweden, under Professor Sidney Dekker. He completed his PhD in Social Science at Tilburg University, Netherlands, under Professor Kenneth Gergen.

Ivan is an international consultant and organizational coach who focuses on topics related to human factors, the “New View” of human error, real-time risk perspectives, holistic safety, learning from events, organizational dialogue, development of high-leverage learning products, and the connection between resilience & high reliability organizing.

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