2020 Learning:A Vision For The Future

Andy Evans9 May 2019

RAeS Human Factors Group: Engineering

Cranfield University

© Aerossurance Limited 2019

1997 20011990

Continue to

believe an

illusion

See the

truth

Maintenance Error: Are We Learning?

Traditionally:

Learning through Training

and

Report – Investigate – Learn (Repeat)

Training / Teaching: The act of imparting skills and/or knowledge

Learning: The act of gaining skills and/or knowledge

LearningTraining / Teaching

70:20:10 - A concept not a prescription

70% 20% 10%

Learning By/While Working

Social / Informal Learning

Formal Courses

• UK CAA said in 2016: …the extent to which detailed error investigations are conducted appears to have decreased…

• Possibly due to the [low] perceived value…

• What is the quality of investigators?

• How much is really being learnt about other people’s occurrences?

Report – Investigate – Learn (Repeat)

• [The] focus on incident data [and the associated forms, procedures and databases] is also the source of many of our current problems.

• We collect too much and do too little.

• Learning depends critically on the less visible social processes of

– inquiry,

– investigation and

– improvement

• that unfold around incidents.

Source: Carl Macrae BMJ 2016

Source: Nimrod Review© Crown Copyright 2009Used with permission

Derived from James Reason

One organisation’s SMS Manual:

• 46 pages

• 18 pages on culture (40% of manual)

• Of those 18: 14 about determining culpability (30% of manual / 78% chapter on culture)

Source: Nimrod Review© Crown Copyright 2009Used with permission

78%22%Is this a balanced culture?

Ayes to the left

The tool loss

Noes to the right

The release of an aircraft with a

reported lost tool

Indicative vote: Where Should we Focus?

Published Nov 1997

Usually the human is considered a hazard...However there is another perspective…the human as hero…

Published Dec 2008

Published Nov 2010

Psychological safety is rare… a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes.

So what is the future?

Does your Safety Database Facilitate Learning?

BARSOHO V3 December 2016

Maintenance Observation ProgramConceived based on two trials we did plus research at Cranfield

MOP is about working

with

front line personnel to

learn and improve

• Is your organisation being innovative enough with how you facilitate learning?

• How do you share and encourage lessons learnt?• Are you learning from other people’s lessons?• Has your organisation got the cultural emphasis right?• Do you have true ‘psychological safety’? • Do you treat your people as heroes not hazards?

Questions to Reflect on Innovation

CI

Both

andy.evans@aerossurance.com

@Aerossurance

Questions?