WHAT IS AN OPERATIONAL LEARNING REVIEW?
The OLR is about learning for continuous improvement. It is a proactive tool to support and enhance the SMS,
proven by sound academic foundations.
Uses 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 done and why it made sense for people to do what they did.
Creates a psychological safe space for people to share their experiences.
Identifies both where work went well, where it did not, and why.
Captures information outside of current reporting systems, adding learning and insights
into the SMS that we would not have otherwise known.
WHAT IS AN OLR USED FOR?
Anything you want to learn from, understand, investigate, research, find out the things you would not have otherwise have known.
Learning from all operations, both undesired outcomes and things that went well.
The OLR also allows us to identify trends, themes and patterns in data for proactive safety management.
Incident investigation including Annex 13 investigations
Fatigue Risk Management
Multiple departments in high-risk organisations such as pilots, cabin and engineering.
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.
ASSUME POSITIVE INTENT
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 center, 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.
WORK AS DONE
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 behaviors, 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.
CURIOSITY WITHOUT JUDGEMENT
"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 behavior?", 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.
LEARN MORE ABOUT LEARNING REVIEWS
This webinar made in conjuntion with the British Airline Pilots Associaton covers the principles behind the Operational Learning Review, discusses practical applications and explains how it feeds into the SMS.
THE ACADEMIC RIGOUR OF LEARNING REVIEWS
LEARNING REVIEWS IN YOUR ORGANISATION
We can run Learning Reviews and work with you to enhance your SMS on small or large-scale projects. We can help if you want a deeper and comprehensive understanding of :
A specific safety-related issue
How well your safety systems, procedures and practices are working
What's going on in your organisation outside of conventional reporting systems
How learning reviews
An independant overview of safety in your organisation
LEARNING REVIEW FACILITATOR COURSE
Learning Reviews are a powerful tool for improving safety outcomes and promoting a culture of continuous improvement. By learning how to implement and benefit from Learning Reviews during our 3 or 4 days courses, you can equip yourself with the skills and knowledge necessary to evolve the safety and learning culture in your organisation.
CONTINUOUS IMPROVEMENT CORE CONCEPTS COURSE
Transform your approach to safety with our comprehensive education packages that offer the latest insights in safety theory and practical application. From the boardroom to the frontline, equip your organization to embark on a journey of safety evolution and continuous improvement.