Learning From All Operations

In an increasingly interconnected and complex aviation system, it is imperative to learn not only from things that rarely go wrong but also from things that go right. Data collection needs to expand from a focus on hazardous events to analysis of routine operational data. The Foundation believes it is time for a fundamental shift to learn from all operations and events — not just from those that are unwanted. In July 2021, the Foundation published a whitepaper, entitled Learning From All Operations: Expanding the Field of Vision to Improve Aviation Safety, as a call to action to managers and executives who are accountable for safety in their organizations. 

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Concept Notes and Case Studies

In order to facilitate learning from all operations there is a need for a conceptual framework that incorporates taxonomies and concepts based on the existing risk and hazard terminology but expanded to include resilience and adaptation best suited for use for both abnormal and normal operations. The suggested framework should be suitable for understanding of work-as-done and for collecting and analysing diverse sources of data on the real world resilient behavior of operators. To define the Learning From All Operations conceptual framework, the Foundation offers the following series of Concept Notes. Also below is a case study of how Learning From All Operations was used to select a strategy to mitigate an operational safety issue.

Concept Note 1: The Need for Learning From All Operations

Concept Note 2: Systems Approach 

Concept Note 3: Safety Envelope and Operational Limits Assumptions

Concept Note 4: Patterns of Operational Resilience

Concept Note 5: Three Forces Model of System Adaptation

Concept Note 6: Mechanism of Operational Resilience

Concept Note 7: Pressures, Adaptations and Manifestations Framework

Case Study: Take-Off Rotation

Case Study: Learning With Flight Replay Animations 

Additional Resources

How Operators Can Create Safety in an Uncertain World, a paper by James Burnell, Tom Laursen and Joji Waites, examines the evolving understanding of “complex adaptive systems” in which it is accepted that uncertainty is part of everyday operations. The paper also explores “adaptive capacity,” which helps achieve high reliability despite the challenges brought by complex operations.

Download the paper