Why should we use Raise?
Organisations rarely fail because nobody saw the problem. They fail because what somebody saw never reached anyone who could act on it, and never survived long enough to change what the organisation did next. Below is what the public record says about both halves of that sentence: the cost of losing lessons, and the measurable value of institutionalising them.
of individual contributors say they often watch colleagues stay silent when they hold a differing opinion. 1
of every dollar invested in projects is wasted through poor performance — roughly $2 trillion a year worldwide. 5
reports collected by aviation's confidential reporting system since 1976, producing 5,200+ safety alerts. 10
People already see the problem. Most of them say nothing.
Every survey below asked a variant of the same question: did you have a concern, and did you raise it. The gap between the two is the raw material a lessons-learned system either captures or loses.
The most common reason clinicians gave for staying quiet was not fear. It was ineffectiveness — the belief that speaking up changes nothing.
38% cited it, ahead of the presence of patients (26%) and an unpredictable reaction (25%). 4
Waste tracks how well an organisation recycles its own experience.
The Project Management Institute has surveyed thousands of practitioners annually for over a decade. Its waste figure fell as project maturity — including knowledge transfer and recognising lessons learned — rose across the surveyed population. 5
Two organisations that produced the lesson, filed it, and repeated the failure anyway.
Both had formal investigation machinery. Neither case is a story about missing information. Both are stories about information that existed and did not change behaviour.
NASA
Challenger to Columbia
The Rogers Commission criticised NASA in 1986 for failing to respond adequately to internal warnings before Challenger. 8 Seventeen years later the Columbia Accident Investigation Board found the same organisational conditions back in place.
“By the eve of the Columbia accident, institutional practices that were in effect at the time of the Challenger accident — such as inadequate concern over deviations, a silent safety programme, and schedule pressure — had returned to NASA.”
The Board’s own conclusion was that the agency “has not demonstrated the characteristics of a learning organization”, and that the breach in the wing was produced “not simply by debris, but by holes in organisational decision making”. 9 One board member described finding “still evidence of a silent safety program with echoes of Challenger”. 11
Boeing 737 MAX
Five months, twice
Both accidents began the same way: a single angle-of-attack sensor failed, MCAS pushed the nose down, and the crew could not recover. 12 After the first crash, the knowledge required to prevent the second existed in several places at once — inside Boeing, inside the FAA, and inside the airline that would suffer it.
“The airline that tried to prevent the next crash became the next crash.”
American Airlines pilots confronted Boeing in a recorded November 2018 meeting. A Boeing vice-president told them the Lion Air loss was effectively a once-in-a-lifetime event and that crews should not be overloaded with unnecessary information. A pilot replied: “We’re the last line of defence to being in that smoking hole, and we need the knowledge.” 14 The software fix was still in development when ET302 went down.
Two systems that turned individual observations into institutional memory.
Both were built after a specific failure to circulate what someone already knew. Both are now widely copied. Neither relies on people being braver than they are.
The Aviation Safety Reporting System
In December 1974, TWA 514 flew into a mountaintop near Dulles after the crew misread a clearance. The NTSB investigation surfaced a disturbing finding about knowledge that existed but had not been shared beyond the operator who held it. 15 NASA and the FAA responded by building a confidential, immunity-backed channel where anyone in the system can report what they saw. 16
The model has been adopted by the UK, Canada, Australia, Japan and China, and copied outside aviation — the UK’s National Reporting and Learning System for patient safety, the US fire and law-enforcement incident systems. 18 It remains the largest repository of aviation safety incidents in the world. 10
The After Action Review
Four questions asked after every significant event, run by the participants themselves, with rank treated as irrelevant so any participant can name what went wrong. 19 Wharton describes it as “one of the most successful organizational learning methods yet devised”. 20
Di Stefano, Gino, Pisano and Staats found that fifteen minutes of structured reflection after a task beat spending the same fifteen minutes on additional practice. 21
Peter Senge’s caveat is worth keeping: attempts to import the practice into companies most often fail because “people reduce the living practice of AARs to a sterile technique”. 20
The systems that work share four properties. Raise is built out of them.
This is our reading of the evidence above, not a finding from it. Each column pairs a documented failure mode with the mechanic we use against it.
Intake costs nothing
ASRS works because reporting is confidential and carries no penalty. Raising an issue in Raise takes thirty seconds and no permission.
Against: 45% who will not raise a risk
Every item has an owner
Ethiopian's chief pilot sent his question to an organisation, not a person. Nothing in Raise sits unassigned.
Against: raised, then buried
Escalation is a button
The commonest reason people stay quiet is believing it will not matter. A visible, one-click route up the chain answers that directly.
Against: 38% citing ineffectiveness
The trail outlives the people
NASA's lesson survived on paper and died in practice across a personnel turnover. Raise keeps the decision, the owner and the date queryable.
Against: rediscovering the same blocker
What the sources above do not establish.
No source measures a tool like Raise. The aerospace cases and the PMI series describe organisational conditions, not software. Nothing here shows that adopting a product changes outcomes; the causal claim above is ours.
Survey figures are not directly comparable. The four bars above come from different populations, countries, years and question wordings. They point the same direction; they are not one dataset.
ASRS volume is not a safety statistic. SKYbrary cautions explicitly that report counts are frequently treated as a statistically valid dataset when they are not — voluntary reporting rates move with reporting culture as much as with hazard. Report totals show reach, not risk reduction.
Blame in the 737 MAX case is contested. Ethiopia's final report attributed the accident to Boeing; the NTSB's published critique concluded the crew did not follow Boeing's post-Lion-Air procedures and should bear part of the probable cause. The failure to circulate MCAS information is documented; the apportionment is not settled.
The 70% project-failure figure is not used here. It is widely quoted and traces to an unscientific 1993 estimate in Reengineering the Corporation; McKinsey's later work suggests total change failure is far rarer.
Everything cited above, in order.
- 01CNBC Make It, "6 in 10 employees are hesitant to speak up at work", May 2026 — Radical Candor survey data.
- 02Perceptyx, "The Psychological Safety Gap", 2026.
- 03MHFA England, research on 2,000 UK working adults, summarised by Arinite, 2026.
- 04SUPS-Q survey, "Speaking up or remaining silent about patient safety concerns in rehabilitation", cross-sectional survey, n=471, 32% response rate.
- 05PMI, Pulse of the Profession 2018 media release — 9.9% waste, ≈$2tn/yr. Survey of 4,455 practitioners, 800 PMO directors, 447 executives.
- 06PMI, Pulse of the Profession 2020 — 11.4% waste; 67% more outright failures where PM is undervalued.
- 07PMI, "Success in Disruptive Times" — 13.5%→9.9% since 2013; 92% vs 32% project success.
- 08CAIB Report 2003, Vol. 1, p. 101 and p. 195, quoted in "Learning from Crisis: NASA and the Challenger Disaster".
- 09Human Factors 101, "Columbia Disaster: Uncovering NASA's organisational failures", citing CAIB 2003 p. 177.
- 10NASA Ames, ASRS fact sheet — 900,000+ reports, 5,200+ alerts, 63 studies, 149 ASAP programmes across 59 carriers.
- 11Space.com, "Columbia Report Faults NASA Culture" — Maj. Gen. John Barry on release day.
- 12Leeham News, NTSB critique of Ethiopia's final ET302 report, Dec 2022.
- 13ThinkReliability, "Four Lessons from the Boeing 737 MAX 8 Crashes."
- 14The Guardian, "Pilots confronted Boeing with 737 Max fears after first fatal crash", May 2019, on audio obtained by CBS News.
- 15NASA ASRS, CALLBACK 435: "Safety Depends on Lessons Learned" — TWA 514 and the origin of ASRS.
- 16TRB, "Aviation Safety Incident Reporting: NASA's ASRS" — mandate and 1976 founding.
- 17Van Baelen et al., "NLP of Aviation Occurrence Reports for Safety Management" — 65,656 ASRS reports in 2020.
- 18Safety Science, "The dynamics between voluntary safety reporting and commercial aviation accidents" — international adoption of the ASRS model.
- 19CIA Center for the Study of Intelligence, "The Case for After Action Reviews in Intelligence"; AAR history, 1981–82.
- 20Wharton Executive Education, "After-Action Reviews: A Simple Yet Powerful Tool", including the Senge caution.
- 21Di Stefano, Gino, Pisano & Staats (2016), reflection vs additional practice; with Staats & Gino (2014), Academy of Management Journal.
- 22SKYbrary, "Aviation Safety Reporting System (ASRS)" — caution on statistical claims from report prevalence.
- 23Whatfix, "Change Management Failures to Learn From" — provenance of the 70% statistic and the McKinsey counterpoint.
Your team already knows what is wrong. Give it somewhere to go.
Start with one team. Raise an issue, assign an owner, escalate when it stalls.