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The Learning Product, the Learning Process
Dav: Learning is driven by management, not so much about workers learning the lessons. The success of an incident investigation to be related to how much the incident investigator themself learnt in regard to things that they didn't know before the investigation started. So i think if your an organization, the first practical take what i do is sei send your lessons learned reports to you, to your management, and ask them to tell you what they are going to do differently as a result.