Learning from ONE Event

A white paper for expanding the BOK of TOC by Eli Schragenheim

Introduction

In almost every area of a person’s or an organization’s life unexpected or unexplained results occur. For
example, your largest old client has moved to your competitor. When something like this happens it first
of all triggers efforts to convince the client to come back.

The real question is: what is usually done after the efforts to put off the fire?

In other words, do people or organization make real efforts to LEARN the right lessons from the event?

When something happens that is interpreted as a ‘failure’ the most common approach is to quickly
assume the cause and whom to blame. However, the identification of the operational cause is, many
times, flawed and even when it is right the real faulty paradigm behind the operational cause is almost
never revealed and thus no new understanding is achieved.

When an unexpected success occurs then definitely no inquiry is made to understand how come the
success was not predicted. A huge opportunity to learn about how to achieve real success is being lost.

This paper is about instituting a systematic process of learning to reveal the causes behind unexpected
events, both good and bad and drawing the effective conclusions for superior achievements in the
future. While this is not an easy process as people, especially in organizations, fear to be judged by
others on mistakes many would have done in their place, it is absolutely necessary for any organization
looking for growth and stability to implement that particular learning capability.

SWOT analysis is well known, but how easy it is to reveal hidden threats that could develop into real
threats? At that time it is usually too late to eliminate the threat. People are making mistakes because
one or two of their well rooted basic assumptions, or paradigms, are not in line with reality. What could
be the ramifications of a basic assumption that slowly loses its validity due to developments in reality?
Just imagine that the organization believes it has a decisive competitive edge of providing excellent
availability and does not notice that the competitors have improved their operations and provide good-
enough availability while having other advantages. How many clients moving to the competition are
required for the management to realize that their basic assumption is no longer valid?

The focus of this paper is on organizational learning. Of course, individuals could use the same
methodology, maybe without the part of working in a team, to updates one’s own assumptions about
the relevant reality where he/she lives. But, the greater need is in organizations where shared
paradigms keep the organization from quickly adapting to changes. The proposed methodology could
be viewed as part of the ‘The Learning Organization’ – an interesting and challenging objective. Some of
the insights of this paper could push the current knowledge to better treatment of the higher objective.
Dr. Goldratt already pointed out the need to look for inconsistencies, as signals of what we don’t know.
The term ‘inconsistencies’ could be also verbalized as ‘mysteries’, another term used by Goldratt to
describe a signal of failing to

This paper suggests expanding the current TOC knowledge, especially in the area of the TP, by examining
the power of organizational learning from a single event. The problematic area is that people within the
organization often behave according to paradigms that are not in perfect match with reality. The result
is the occurrence of repeating mistakes that harm the organization performance. Those mistakes could
cause various threats to the organization, which makes fast identification and corrections of the
mistakes even more vital for any organization.

The practical problem is that mistakes are not always easily identified once they are done. More,
mistakes that are identified are often replaced by other mistakes. The organization is exposed to events
that signal that something wrong, or just surprising, has just taken place. If a process is implemented
that is able to identify the events that might have been resulted from flawed paradigms, and then
identify the right flawed paradigm, then it’d be possible to quickly update the flawed paradigm and
correct its negative ramifications. This is a highly desirable result that significantly reduces the negative
impact of repeating mistakes and would make changes, including the implementation of TOC within
organization, much smoother. The potential to quickly identify various threats, which were developing
outside or inside the organization, but not fully recognized so far is of a special importance to the
stability of the organization.

The TP tools were built to learn from several undesired effects or to support the prediction of both
desired and undesired results from a decision, action or a new effect in reality. Using cause and effect
to identify the right flawed paradigm behind an event requires some changes to the TP that are going to
be discussed in the paper.

The earlier version of suggested process has been already presented at the first TOCICO conference at
Cambridge. A paper entitles “Learning from Experience – a structured Methodology based on TOC” by
Eli Schragenheim and Avner Passal was published by Human Systems Management 24 (2005), pages 95-
104. The objective of this white paper is to gain formal recognition as part of the TOC BOK.

In this paper the format is based on Standing-on-the-Shoulders-of-Giants (SOG) by Goldratt. It puts a

special emphasis the unique area of learning from a single event and the changes to the TOC/TP
methodology it raises. The paper also advocates using a team to do the learning. It also refers to Eli
Schragenheim’s presentation and definition of the “Transition Period” (TOCICO, Palisades, 2011).

Dr. Alan Barnard, has used some of the insights to develop an auditing process on planning, emphasizing
the gap between the expectations in the planning and the actual outcomes. It many ways this is a
complimentary process to what is suggested here.

Learning from ONE Event

SOG Step 1: Identify a giant

This white paper certainly stands on the shoulders of Dr. Goldratt and his TP tools, mostly from the CRT
and the Cloud tools, which are used to identify the root problem in reality and one, or several,
assumptions that can be challenged and by that lead to solving the problem.

SOG Step 2: Identify the enormity of the area not addressed by the giant

This paper points to events that are “surprising” to the organization’s key managers and use them as a
trigger to learning and possibly identifying threats or even new opportunities. A surprise can be good or
bad. The main argument is that any surprise is a signal that a certain paradigm that exists in the
organization is flawed.

I claim that a surprising event is an opportunity for the organization to fix a flawed paradigm and then
build the appropriate future-reality-tree (FRT) to fix all the policies and norms that the flawed paradigm
is impacting.

There are two different categories of surprising events:

One category consists of events that are in conflict with clear a-priori expectations, like failing to
achieve a planned objective or when a forecast or any other type of prediction ended up is a significant
gap.

The second category is when an event happens in complete surprise – without any a-priori prediction,
like when a serious embezzlement is discovered by coincidence.

The methodology employed by Dr. Alan Barnard is clearly directed at the first category and especially
when the intent is to check the gap between planning and execution. The methodology this paper is
focused on one surprising single event, like when major failing of a test everybody have been pretty
certain is just a formality.

SOG Step 3: Get on the giant’s shoulders

The term UDE – an undesired effect - is a central term in the TP. A list of several UDEs, defined
according to the intuition of several people, is the trigger to map the main cause and effect relationships
in the environment. That process ends up by revealing the core problem that lies behind all those UDEs.

Historically Eli Goldratt has defined the term “effect-cause-effect” as the key basic tool to speculate and
validate a causal relationship in reality. The terms refer to an effect in reality that we wonder what have
caused it. We speculate that the ‘effect’ was caused by a ‘cause’, or several causes happening together,
that explain the existence of the ‘effect’ in our reality. However, it is not clear that the speculated
‘cause’ truly exists in our reality. In order to validate the existence of the ‘cause’ another effect in reality
is predicted, and if found to exist it serves as a validation. This validation by another effect was a key
factor in Goldratt’s idea about the application of the scientific approach to management.
However, practical difficulties in covering every arrow in a tree by a validating effect moved Goldratt to
stop demanding this validation for the common use of TP.

SOG Step 4: Identify the conceptual difference between the reality that was improved so
dramatically by the giant, and the area untouched.

In the particular environment of learning from a single event the validation of hypotheses becomes
absolutely necessary. Thus, the original tool of effect-cause-effect is used here again, sometimes in
certain variations.

An UDE is an occurring negative effect that happens continuously over time. Thus, the cause and effect
are verbalized in the present tense. When we inquire a specific occurrence of something in reality we
need to verbalize the past causalities in the past tense. More analysis of the required changes in the use
of the TP would appear later.

Regular CRTs reach their objective when the core problem is identified. The core problem is then
translated into a conflict cloud. The underline assumption is that the members of the organization
recognize and actually “live” with the conflict, and are aware to both the positive and the negative sides
of the conflict. The process of the cloud helps to verbalize hidden assumptions that many times lead to
an insight of challenging one or more of the assumptions and this leads to a solution. This challenge of
an assumption is the same as the concept of “flawed paradigm” used in this article. However, in the
case of a surprising event the way to reveal the flawed paradigm cannot be done though the use of the
cloud, because it is not self evident that person that has acted based on the flawed paradigm has been
aware of the conflict. In other words, when a surprise happens the people involved have not been aware
of any possible negative effect of their actions. The experience of being surprised means we’re not
aware of its possibility and this is exactly when the flawed paradigm is not part of a cloud that the
organization is aware of.

Once the solution, having a new updated paradigm instead of the flawed one, which is the same as the
challenge of a hidden assumption behind a cloud, is achieved we need to develop the future-reality-tree
(FRT) to establish all the ramifications of the new understanding. In the specific area we deal here
where the flawed paradigm is very specific to a particular case without the wide view that the CRT gives
there is a need to generalizing the new understanding in order to create a wider scope new paradigm.

Another conceptual difference is the use of a team to conduct the learning process. So far TOC did not
clearly defined who should carry an analysis, even though a consensus has to be reached. Creating a
team generates an opportunity to create a different structure that is independent to a certain degree
from the formal hierarchy of the organization and is used to handle behavioral issues that might block
the process of learning.

SOG Step 5: Identify the wrong assumption

The main assumption behind the term UDE is that most people within the environment are aware of the
effect and recognize it as an undesired.
An even stronger assumption of TOC claims that the reason the UDE has not being solved by now is
because it is a part (one leg) of a conflict cloud. Thus, the way to identify and remove a faulty paradigm
is to create the cloud and reveal the hidden assumptions behind it.

However, the area we focus on is characterized by a special sort of an UDE that is a SURPRISE! In other
words an event that is not properly understood. This means there is a flawed paradigm that we
currently don’t recognize it as flawed and this surprise is an opportunity for us to get to identify it. This
also means that the conflict around that flawed paradigm is not known at this stage.

Generally speaking there is another basic assumption in TOC that people are basically rational. Goldratt
said “all people are good”. Somehow this broad statement leads to looking for the rational reasons
people have in mind. However, people have unexplained fears and automatic pattern of behavior that
are not rational and not even recognized by the people themselves. Striving for efficiency, even when
filling in the dishwasher at home, having no one measuring the “efficiency” of handling the house
economics is something we ourselves are often blind to. This paper is not going to touch upon this
aspect here, but let’s recognize the fact that learning in itself is frightening to many people. One of the
missions of TOC, certainly by using the TP techniques, is to achieve a culture of being open to other
ideas, and recognizing the facts that we all are making many mistakes, and thus the best attitude is to
learn from them.

SOG Step 6: Conduct the full analysis to determine the core problem, solution, etc.

Observation: When a surprise happens it usually causes fear, because most of the time this surprise
means bad news leading to the recognition that a “mistake” has been made leading to finger pointing.
When it does not lead to finger pointing it means no one would give the surprise any more thoughts.

In the rarer cases where the surprise means “good news” that were unexpected, there is no trigger to
learn as everything seems fine indeed. However, that fact that people are surprised is in itself negative.
However, the surprising good results induce good feeling so there is no need to emphasis the negative
side of what happened.

The main claim is that any surprise is an opportunity to fix a flawed paradigm. The full process of
learning from one event has six steps.

Step 1: Identify a “surprise” and decide whether it is worthwhile to invest capacity and efforts to reveal
the flawed paradigm.

We are practically surprised every day. Most of the surprises challenge a trivial paradigm that we
identify at once and fix it. If you drive in a snow and your car slide a little – you get the idea fast enough
that you need to care about the impact of the snow on your car. While being aware that you do make a
small change to a certain paradigm could be useful to firmly update your paradigm, the immediate
cause and effect are so clear that most people are doing it right.

The problem arises when the surprise is significant but the cause and effect behind it are not so
straightforward.
A leading example: Imagine that an important client, let’s call it ‘ClientCompany’, with whom you
(CompanyA) have had excellent relationships for five years, lets you know that following their
management decision CompanyA would stop working with you. Such an incident usually causes
immediate response in a try to reverse the decision.

Question: No matter whether ClientCompany’s decision to stop working with your CompanyA has been
reversed or not – are you going to investigate what happened?

This paper claims that the surprise itself points to a flawed paradigm within your organization. Even if
the client eventually continues to work with you, ignoring the full cause and effect of the event is not
only a lost opportunity to do better  it is a threat that something similar would happen in the future.
Note, “something similar” is not necessarily a client stopping using your services, it could be a drastic
reduction in sales or a formal inquiry of the authorities to check the quality problems your company is
accused of. Only when the real cause for the surprise is revealed we’d be able to know what future
effect is “similar”.

Should a certain surprise be investigated? The three parameters are:

a. The surprise is significant.

b. The causes are not trivial and thus we are not sure whether the surprise might happen again.

c. The ramifications from preventing the surprise to repeat are significant to the goal of the
organization.

This is a managerial judgment whether to go ahead with a formal inquiry or not, based on the above
parameters. Certainly in times of change the management should be ready to carry formal inquiries
because it could be critical to the success or failure of the change.

Step 2: Create a team to inquire the surprise

In the organizational context the learning has to yield lessons for the organization as a whole. Would
the personal learning be sufficient?

The case for using a team comes from the following concerns:

a. It is difficult for one person to identify a flawed paradigm that the person had himself/herself.
Carrying such an analysis with several people increases the chance of learning the right lessons.

b. When the team includes people who were involved in the specific event and other people that might
be described as external to the event we have the best chance of merging the current intuition of the
cause and effect with the devil’s advocate approach of the other people.

c. The fear of the involved people of being blamed is vastly reduced when a team, which consists of
people involved together with people uninvolved in the event, tries together to understand the
objective cause and effect.
d. Once facing a surprising effect the natural tendency is to come up with the first plausible explanation
and refrain from searching after possible other ones. A team can reduce this tendency.

The normal size of such a team is 3-5 people, taken from various levels and functions within the
organization.

Step 3: Verbalizing clearly the gap between prior expectations and the specific outcome

The focus of the learning is the surprise, or the gap between prior expectations and the outcome. Once
facing a surprise is it clear what is the gap that would be the center of the learning?

Let’s distinguish between two different situations:

a. The prior expectations were clearly verbalized, like in detailed planning. In this case the gap is pretty
clear to start with. Let’s only emphasis that too many plans do not clearly define the realistic results
that they like to achieve. Good planning, though, should define the minimum and maximum level of
results expected, and by that signal what would be considered as a surprise. Alan Barnard, in a
presentation at 2012 TOCICO conference, has been focusing on this aspect of learning from experience,
including the need to clarify the realistic expectations within the planning.

b. There are no specific prior expectations, but the intuition of people is that something unexpected has
happened. In this case the clear verbalization of the gap is a must.

The leading example of a surprising announcement of ClientCompany that the mutual business
relationships came to an end falls clearly into the second situation.

What is the gap in the example? It is self evident that such an announcement of a client company is
highly undesirable, but is it a “surprise”? If your company never lost a client before it might come as a
surprise, meaning no one expected any client to leave. However, most organizations have already lost
clients, so they should not be overly surprised from such a leave.

Unless, the surprise is coming from a different angle. The surprise could be that there was no signal that
the particular client is going to cancel the future relationships, while in all previous cases there were
enough signals to that effect. If this is the case then the gap is:

Prior expectations: We know a-priori of difficulties or conflicting interests within the client, so we are
ready for the formal announcement.

Actual event: We did not see any signal that ClientCompany is going to cancel their business. Yet, it
did happen.

My own experience in leading inquiry teams shows that verbalizing the gap is a significant step, which
tales considerable time to get consensus of all the team members. The next steps went much more
smoothly due to the agreement on the focus of the learning.

Step 4: Gather a long list of possible explanations

The team has to create a list of as many as possible broad explanations to the event. This sub-step is
absolutely required in order to force the team members to cover a wide area of possible explanations to
the gap.

When we have a gap there would be hypotheses that would explain it either from the expectation side,
meaning the flawed paradigm is that we have expected something that is not in line with reality, or from
the execution side.

For example:

Hypo1: A key person in ClientCompany had a personal reason to move the business to a competitor.

Note: This hypothesis is on the expectation side: you cannot rule out personal inclinations that have
nothing to do with us! And in such a case we would not get usually any prior signal.

Hypo2: ClientCompany was pissed off because of bad quality/delivery to the point that they did not
communicate their dissatisfaction.

Hypo3: There is at least one competitor who offers improved price and/or service to ClientCompany.
The client assumed we would be able to match the price.

Hypo4: Someone passed bad information (which could be true or untrue) to ClientCompany about
CompanyA and they did not bother to validate it.

Hypo5: Our salespeople do not listen enough

HypoN: It is just a rare statistical fluctuation without any apparent reason.

This kind of hypothesis is only the very last one – assuming everything else is about right and thus there
is nothing to learn apart from the fact that sometimes we are merely unlucky.

Note, I use the example to demonstrate the proposed process. Given a real case the above list of
hypotheses is far from being complete.
 A focus search for meaningful data

By Eli Schragenheim

One of the major, yet common, mistakes of managers is to look for as much data as possible. Data
has to support information, defined by Goldratt as “an answer to a question asked”, that is part of
decision making. Trying to go through ocean of data almost ensures confusion. Undirected search for
meaningful data is quite common and causes huge damage.

How should we obtain the information that is truly required? By asking ourselves what could make a
significant impact on the decision. For instance, if you consider changing significantly the price of one
of your products and wonder what might be the reaction of the market, you would like to know
whether someone else, not too long ago, has changed the price for a product for a similar market
segment and what has been the reaction of the market. Inquiring very wide history of price changes
at different markets might be very confusing, sending conflicting messages about the outcomes, and
eventually creating more damage than benefits.

The situation this paper deals with is even more critical regarding the danger from unfocused search
for meaningful data. Being surprised means you are, to a certain degree, out of your natural
intuition. Becoming confused by the data is enemy no. 1 of every one who looks to understand the
cause and effect behind an event.

The process proposed here starts with broad hypotheses – BEFORE looking for any data, based just on
the occurrence of a surprise. By looking to validate or invalidate every hypothesis we look only for
those data elements (actually information) that can clearly validate or invalidate the hypothesis.

Step 5: Identify the flawed paradigm

This step is clearly divided into three sub-steps. First the team needs to fully verbalize the logical
connections for each hypothesis explaining how it might explain the gap. Then sub-step 2 requires the
team members to actively look for the ‘operational cause’  the group of sufficient facts that have truly
caused the gap. The third sub-step would force the team members to dive down from the operational
cause to identify the flawed paradigm that caused the operational cause.

Sub-step 1

Each hypothesis is checked for its logical connection leading from the speculated facts to the gap. In the
leading example, let’s first check the second hypothesis (Hypo2). The simple initial logical claim is:
This is a logical possible explanation of the gap. The specific hypothesis explains the surprise how come
there was no signal: the client was too much pissed off.

Note, this is still the hypothesis. The two entities at the bottom need to be validated in reality!

Certainly all the hypotheses should be built to this level before going to sub-step 2.

Sub-step 2

The main body of this sub-step is to check facts that would either invalidate or validate the hypotheses.
The emphasis on invalidation is to rule out the definitely wrong hypotheses. Note, that it could well be
that more than one hypotheses is validated – so, the event was the result of a combination of effects. It
is less likely that there will be more than one flawed paradigm and in such a case it is important to
assess which one has the stronger and wider effects.

There are three broad ways to validate the existence of an effect:

a. Direct validation that the effect has existed at the time.

For instance, the effect of “ClientCompany was pissed off because of very bad quality / delivery” might
be validated/invalidated if we directly ask the responsible people in ClientCompany. Not always we’d
necessarily get an answer and in some cases the validity of the answer could be questionable.

b. Using the effect-cause-effect basic structure. This means that if we can convincingly argue that if
that effect was truly exist at the time, then it had also to cause another effect (on top of the effect we
claim is caused by that effect) and if we can validate the existence of that effect, then we have validated
the existence of the effect.
For instance, the same effect of “ClientCompany was pissed off because of very bad quality / delivery ”,
might be validated if we find other clients that got very bad quality shipments and were also pissed off
by it (not to the extent of breaking the relationships). Another possible validation might be finding out
that ClientCompany is warning other clients from the bad quality ClientA is producing lately.

c. Identifying a cause for that effect that was active at the time.

The same effect of “ClientCompany was pissed off because of very bad quality / delivery” could be
validated if we look for a likely effect that would have caused it and validate that the causing effect
truly happened. This is a useful step as anyway we’d need to dive down to the root operational cause.

Suppose we have found out that a whole team, consisting of three operators, has been replace by new
people and that the last two shipments included ultra complicated jobs. This could be a probable cause
that partially validating that the effect that two shipments have been their quality compromised.

A general comment: When we speculate on cause-and-effect in the past we need to acknowledge the
role of uncertainty. In a regular cause-and-effect structure the following basic relationship looks good:

However, when we consider a particular case we cannot be certain that the following has happened:

Validity is not 100% certainty. Still, we can use the concept of validity to make decisions that most of
the time would v good ones. Certainly when we like to learn we need to strive for good enough validity
and not stretch the requirements too much.

Back to sub-step 2.

The objective is to uncover the operational cause. Looking at the full cause-and-effect structure we get
now:
The effect of “A team of new operators worked on the last two orders for ClientCompany” looks as the
factual fact that led to the gap. We should now proceed to the third sub-step.

Sub-step 3

The mission now is to ask the question: How come the operational cause has happened? The regular
TP would call for constructing a cloud. However, in such a case that did not happen a lot before there is
no obvious conflict.

So, how come that CompanyA has let a team of new operators, supposedly well trained (this has to be
checked in reality and validated) to deal with complicated orders without, probably, special quality
check and attention of more experienced supervisor? Diving down the logic has to confirm that special
supervision did not take place. Let’s suppose that this has been validated.

The existing paradigm, which worked fine so far, has to be carefully verbalized. In this particular case we
could verbalize it as:

Our operators have been properly trained and thus are equal to the more experienced ones

When people discover a discrepancy in a paradigm then the automatic response might be to reverse the
paradigm. This is a very erratic behavior. One has to realize that the paradigm had been a good match
to reality in many previous cases. Thus, the team needs to record the cases where the paradigm does
work and what is the difference between this case and the previous ones that made the paradigm to be
wrong.

Every paradigm is actually a small branch of cause and effect. Let’s verbalize the original paradigm:

When we notice that in this particular case the operator’s job was not routine then we could update the
original with the following paradigm:

The team should be challenged to generalize the new paradigm to a wider area. Possibly the original
paradigm is thought to be valid not just to operators, but to some other roles within the organization!
For instance, could be that the original paradigm would fit also salespersons.

The team should do their best to verbalize the most generic new paradigm to fit the reality of the
organization and its environment.

For instance, the more generic updated paradigm could be:

Our employees and managers are well prepared for their routine jobs, however when ultra
complicated mission appears then an expert support should be given

Step 6: Develop the necessary changes in the policies and norms

We have reached the stage to develop the future-reality-tree (FRT), deriving all the changes that are
required due to the update of the flawed paradigm. In most way this is quite a regular FRT.

What makes this process of developing the FRT a little different is that the desired-effects (DEs) are
usually the future prevention of threats that could have happen due to the flawed paradigm.

As the whole learning was initiated based on one UDE – the gap between prior expectation and an
actual event, the ramifications of the FRT could and should look much wider than the original objective.
This sort of FRT requires more care and attention from the team on charge of the learning, because the
ramifications of a flawed paradigm could be pretty wide, touching upon issues that were not mentioned
at all in the previous analysis.

In the leading example we could assume that examining again the quality of work from new employees
might lead to different policies in Operations, Sales and probably also analyze the performance of newly
promoted managers.

TOC has not dealt, so far, with the identification and prevention of threats to the organization, with the
exception of the concept of negative branches (NBRs), which is focused on the threat of implementing
new ideas. The whole process described in this paper is designed to look for flawed paradigms, which
mostly mean potential threats, but also learning to look for potential opportunities that are hidden
below “good surprises”, which this process also handles. The referenced article at the Human Systems
Management analyzes in its appendix an example of such a “good surprise” where a seemingly mediocre
new product has achieved big success.

This paper does not detail the routines of building an FRT, including raising the negative branches and
the trimming of those, as these are all covered in the TOC regular knowledge. The implementation
procedures are also skipped, with the exception of spreading the new learning within the organization,
which is the last step in the proposed process.

Step 7: Sharing the new understanding

Implementing the new policies that stem from the updated paradigm is not the same as sharing the
experience of identifying a common flawed paradigm and updating.

Making a story of the discovery has the potential of delivering the idea of the search for new
understanding through keen interest of those who have not been involved. The bare facts of the event
that initiated the learning are a key in generating interest of other people. Presenting a very concise
version of the final cause and effect tree is a powerful way to communicate the logic, then the policies
that have been changed, including the negative branches and their trimming ideas. While the cause and
effect of the operational cause and the flawed paradigm should be given as relatively short cause and
effect branches, there is no real need to give the full detailed FRT. The shorter we can express the logic
and its impact the higher chance that people who were not involved in the event would learn the
lesson.

Addressing the fear of learning

For the whole process to be implemented in an organization overcoming the obstacle of fear is a must.
People at all levels have good reasons to fear learning from experience:

1. As most learning from experience are triggered by making a “mistake”, actually a flawed paradigm,
and as most managers treat mistakes of their subordinates as a justification to punish the person who
“caused damage”, then there is no desire from any person in the organization to expose to a possible
mistake on his/her behalf.
2. Many people lack the self-confident required for being capable of admitting a mistake, even for
themselves.

Implementing such a process requires a clear strive of top management to change the culture. Instead
of the norm “do not make mistakes” as an appreciated value management should lead to the very
different norm of “making mistakes first time is inevitable, making them again is a sin!”

The author of this paper spent many years in programming. A key paradigm in programming is that it is
not possible to prevent bugs in a computer program. The mission is to be able to identify the bugs and
fix them as fast as possible, without creating new ones in this process. If we can somehow implement
this kind of an insight in the organization in a generic way, then the proposed process would be easy to
implement.

The TOC culture certainty backs up the need for learning from mistakes through its “challenge your own
hidden assumptions” insight. This process makes this insight clearer and stronger and should be, to the
author’s view, an integral part of any TOC implementation.

The author’s presentation “The Transition Period” suggests making special efforts in any TOC
implementation, actually in any significant change period, to spot events that look surprising. In such a
transition period many employees lose their basic intuition and fail in comprehending the full
ramifications of the change. Such a learning process could answer the bigger need of any change: have
good control on the organization throughout the transition period.

Experiencing the process

The main ingredients of process have been developed in the late Nineties by Eli Schragenheim and Dr.
Avner Passal. It was implemented in several security-oriented organizations in Israel. The
implementations we not TOC oriented and the TP was not used. Instead we have emphasized the need
for logical verbal explanation, and we have stressed the need to check sufficiency, which seems to be
the most common mistake people do when they offer a logical explanation.

Within those implementations the author has led several teams to inquire certain events that were
identified not just as surprising but were also quite painful to the organization. While details of the
specific inquiries cannot be revealed here there are two effects that seemed to be common to all:

1. Verbalizing the gap took relatively long time, but after it the rest of the inquiry went pretty fast.

2. The teams were amazed by the fact that the general ramifications of the discovery of the flawed
paradigm were much broader than they could imagine at the start of the inquiry – given the event.

Dr. Alan Barnard has developed a complemented way, using the insights from the paper by Eli
Schragenheim and Dr. Avner Passal to audit VV implementations and has applied to inquire gaps
between the planning and the execution.

References
1. “Learning from Experience” – Eli Schragenheim , a presentation given at the first TOCICO conference
at Cambridge, 2003.

2. “Learning from Experience – A Structured Methodology Based on TOC”, Eli Schragenheim and Dr.
Avner Passal, Human Systems Management 24 (2005), 95-104

3. “Learning from experience: Why we should, why we don’t and how to do it”, Dr. Alan Barnard and Dr.
Barry Morgenstern, a Presentation at the TOCICO 2012

4. “The Transition Period”, Eli Schragenheim, a presentation at the TOCICO 2011