The Operations Learning Review is about learning
from normal work for continuous improvement.
It is a proactive tool to support and enhance
your existing SMS, proven by solid
WHAT IS AN OPERATIONS LEARNING REVIEW?
Takes a systems approach to safety management with learning and improvement as the objectives. This expands on conventional approaches of solely 'preventing accidents'.
Helps us understand work as it is done in the real world and why it made sense for people to do what they did at the time, creating contextual and meaningful data.
Creates a psychological safe space for people to share their experiences.
Identifies where work went well, where it did not, and why.
A complementary data stream to the existing SMS.
BENEFITS OF THE OLR
LEARNING FROM ALL OPERATIONS
Every operation offers safety insights: continuous learning is key.
SUPPLEMENTARY DATA STREAM
A deep understanding of normal work, finding out things you would not have otherwise known
ADD CONTEXT TO DATA
Safety data enriched with context ensures a comprehensive understanding of your safety system
SPOTLIGHT ON ADAPTIVE CAPACITY
Proactive tool to identify system boundaries and the ability of our front-line experts to adjust, respond and thrive.
SUPPORTS PSYCHOLOGICAL SAFETY AND JUST CULTURE
Safety insights flourish where trust and openness are nurtured.
Event and Incident investigation including Annex 13 investigations.
Deep understanding of specific safety issues.
Fatigue Risk Management.
WHAT IS AN OLR USED FOR?
Anything you want to learn from, understand, investigate, research.
Learning from all operations: the OLR can help you understand both undesired outcomes and things that are working well.
The OLR also allows us to identify trends, themes and patterns in data for proactive adn wholistic safety management.
THE OLR PHILOSOPHYcore concepts of our approach
Systems thinking is a way of approaching complex systems by considering how they function as a whole, rather than focusing solely on individual parts. It involves understanding the relationships and interdependencies between the parts of the system, and how they contribute to system behaviour. Incidents and accidents in complex systems do not come down to a single cause or factor. Instead, they involve multiple and complex factors that interact on the day. Through understanding these interactions through learning reviews, it becomes possible to identify opportunities for intervention and improvement, as well as potential unintended consequences of changes made to the system.
People do what makes sense to them given the information they had within the context at the time. If it didn't make sense to them, they wouldn't have done it! Reports often cite that people 'failed to/ should have/ didn't follow procedure'. This is describing something that never happened or 'work as imagined'. Instead, we use the Learning Review to understand how events unfolded and the factors shaping behaviour, decisions and performance. By examining the context in which the event occurred, we gain a deep understanding of the performance shaping factors that contributed to the event. We then apply this knowledge to develop more effective safety strategies and make the system more robust in the future.
Nobody wakes up in the morning and decides to put themselves or others at risk. What happens on the front line and how procedures are used are often not how we think work happens. People make trade-offs and have to adapt to challenges, pressures and dynamic conditions to get their work done on a daily basis. Because of this, we assume people come to work with the intention of doing a good job. This mindset shifts the focus from blaming individuals for mistakes or errors to addressing the underlying systemic factors that contribute to events. It creates a positive environment that puts the human at the centre, a psychological safe space where people can open up and share. Rather than assuming people are the problem, we consider them the solution and seek to learn from their experience.
Safety systems and risk assessments are based on assumptions of how our procedures and practices are carried out, 'work as imagined'. In practice, these idealised assumptions may or may not always be valid. We work in complex systems which are constantly evolving and outcomes are not entirely predictable. Frontline 'work as done' is shaped by a range of factors that influence how workers approach their tasks, make decisions, and interact with others in the system as they adapt to the conditions on the day. By learning about the actual work practices and behaviours, we gain a far more realistic picture of how the system operates in practice and identify mitigations that are more effective for a complex and dynamic world.
"What were they thinking?" is a common initial reaction to a safety-related event, but approaching investigations with a mindset of curiosity without judgment can lead to a more productive analysis. By asking questions such as "How did they come to their decisions?" and "What was influencing their behaviour?". investigators can gain a deeper understanding of the underlying factors that contributed to the event. This approach allows for a more objective and comprehensive analysis of the incident, minimizes biases and initial reactions, and promotes a genuine discovery of what happened.
CURIOSITY WITHOUT JUDGEMENT
ASSUME POSITIVE INTENT
WORK AS DONE
ACADEMIC RIGOUR BEHIND LEARNING REVIEWS
Throughout his PhD research, Pete McCarthy has dedicated significant effort to investigating the operations learning review method in depth. His extensive research and testing has revealed that this method is a robust and reliable tool for assessing and analysing work-as-done across all operations – providing insights for continuous learning, safety and excellence. The empirical data gathered, coupled with rigorous analytical procedures, have consistently demonstrated the method's validity, ensuring that it accurately captures and represents individual and system performance. We are then able to identify where any 'drift' toward the boundaries of our safe system may be occurring.
Furthermore, the consistency observed across multiple trials and applications of the operations learning review method attests to its reliability. This means that the method spotlights the areas for understanding across many disciplines, contexts and conditions. Such findings underscore the method's potential as a dependable tool in operational research, offering valuable insights and applications for academia and industry.
OLR COURSES and TRAINING
Want to learn how to set up and run learning reviews?
Interested in implementing a learning approach into your organisation?
Do you want to understand specific safety issues more thoroughly or discover more effective safety management?