2020 learning: a vision for the future · 2019-05-13 · 70:20:10 - a concept not a prescription...
TRANSCRIPT
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2020 Learning:A Vision For The Future
Andy Evans9 May 2019
RAeS Human Factors Group: Engineering
Cranfield University
© Aerossurance Limited 2019
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1997 20011990
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Continue to
believe an
illusion
See the
truth
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Maintenance Error: Are We Learning?
Traditionally:
Learning through Training
and
Report – Investigate – Learn (Repeat)
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Training / Teaching: The act of imparting skills and/or knowledge
Learning: The act of gaining skills and/or knowledge
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LearningTraining / Teaching
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70:20:10 - A concept not a prescription
70% 20% 10%
Learning By/While Working
Social / Informal Learning
Formal Courses
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• 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)
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• [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
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Source: Nimrod Review© Crown Copyright 2009Used with permission
Derived from James Reason
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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)
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Source: Nimrod Review© Crown Copyright 2009Used with permission
78%22%Is this a balanced culture?
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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?
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Published Nov 1997
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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.
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So what is the future?
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Does your Safety Database Facilitate Learning?
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BARSOHO V3 December 2016
Maintenance Observation ProgramConceived based on two trials we did plus research at Cranfield
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MOP is about working
with
front line personnel to
learn and improve
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• 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