I was prompted to write this post by various discussions about whether the Deepwater Horizon/MC252 well blowout represented a failure of KM at BP.
The more I think about this, the more I think it is important to identify what the symptoms are of failed knowledge management. We can't tell if knowledge management is failed in a specific situation, if we don't know what failure looks like.
Making a mistake, is not necessarily or failure of knowledge management. As I said in this post, anyone can make an honest mistake. Making mistakes is part of exploring, of innovating, and of pushing the boundaries. Nobody who ever made a breakthrough, never made a mistake. And I am not alone in this belief; no less a person than Albert Einstein said "Anyone who has never made a mistake has never tried anything new".
Making repeat mistakes is definitely a failure of knowledge management. In this case, the company should have had the knowledge to avoid the mistake a second time, and yet somehow they didn't act on it. You can see this in our failure story number two, where repeat mistakes in successive projects showed that the knowledge management system was broken somehow.
Losing capability is a very obvious symptom of failed knowledge management. This is where a company used to know how to do something, but lost that knowledge. Here is a very good example, where the loss of knowledge about making nuclear weapons cost £69 million to replace.
In safety management, they talk about "lost time incidents" (LTI), where through the failure of the safety mangement system, somebody sustains an injury which causes them to lose time at work, either through treatment or through convalescence. In knowledge management, we could talk about "lost knowledge incidents" (LKIs). This is where the knowledge is or was once available to the organisation, but failed to reach the person who needed to act upon it. Unfortunately a lost knowledge incident is far less visible than a lost time incident. An LTI is visible because a person is not available for work. An LKI is only visible when a mistake is repeated or a capability lost, as described above. Probably the majority of LKIs go undetected.
So how does an LKI happen?
- It can happen when somebody has knowledge, but doesn't want to pass it on. This is a cultural failure.
- It can happen when somebody has knowledge, but has no mechanism to pass it on. This is a failure of the KM framework (and by Knowledge Management framework, I mean the combination of people, process, technology and governance).
- It can happen when somebody has knowledge and has passed it on, but that knowledge cannot be found. This is also a failure of the framework.
- It can happen when somebody needs knowledge, and has the mechanism to find it, but doesn't know that they should look. This I would suggest is also a failure of the framework, because there should be processes for knowledge seeking built into activity.
- It can happen when somebody needs knowledge, and has the mechanism to find it, but they don't want to look for it or don't want to consider it. This is a cultural failure, often known as "not invented here".
What if somebody needs knowledge, has the mechanism to find it, looks for it, finds it, considers it, and then decides that it's not applicable for their situation? I would say that this is not a failure of the knowledge management system, and there must be many many cases when this is the right thing to do. And in the cases where this is the wrong thing to do, it still isn't a knowledge management failure. It's a failure of priorities, or strategy. Knowledge management can only provide the knowledge to the person who needs it, at the time and place of need. It cannot force people to use it, because there may be many external reasons for not using it.
Whether any of these things happened on the MC252 well, we don't know yet. It's certainly not a single repeat mistake; there's been nothing like this happen anywhere, ever before. As the investigation into the cause of the blow out continues and concludes, we can see whether there was an unprecedented combination of repeat mistakes which should have been avoided, or whether the knowledge to avoid this was available to BP, Transocean or Halliburton. Only then will we know if this is a knowledge management failure.
The greatest failure of knowledge management will be if this ever happens again.