VERTICAL

LEARNING

Embedding Lessons Learned

AN D R E W J . D I N G E E

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ANDREW DINGEE

•AV-8B Fighter Pilot, USMC

•FAA Airbus 320 Instructor, United Airlines

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THE FRIENDLY SKIES

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ANDREW DINGEE

•AV-8B Fighter Pilot, USMC

•FAA Airbus 320 Instructor, United Airlines

•Human Factors, United Airlines

•Standardization Officer, USMC

•Accident Investigator

•Review Investigations for CSB

•Author - “Delivering the Right Stuff”

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WE’VE HAD A DROPPED OBJECT

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SAFETY ALERT. NOW WHAT?

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PROBLEM SOLVED

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WHAT’S THE LIFE EXPECTANCY OF A SAFETY ALERT?

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THE SAFETY ALERT WAS SENT OUT…

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LESS THAN 3 MONTHS LATER

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SAFETY ALERTS…

• Only good for worker’s short

term memory boost

• Briefing aid for TBT or Pre-

tours

• No long term corporate

memory

• System will see same incident

again, eventually because the

organization failed to learn.

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ORGANIZATIONAL LEARNING

Organizational or vertical learning is the process of creating,

retaining, and transferring knowledge within an organization and

modifying the behavior of the workforce to reflect new knowledge

and insights.

- Harvard Business Review

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THE FACTS ABOUT DR. DAO…

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GLOBAL CORPORATION: 24 / 7

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WORLD WIDE “SAFETY ALERT” GOES OUT

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2 MONTHS LATER: SUCCESSFUL BEHAVIOR CHANGE

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HOW DO WE EMBED LEARNINGS FROM THIS DROPPED OBJECT?

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THE MOST EFFECTIVE WAY TO MODIFY BEHAVIOR

• New

equipment /

Automation

• Procedures

• Checklists

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EXTRA LAYER OF PROTECTION: C/R CHECKLIST

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WHAT ABOUT LEXINGTON?

• The assumption was pilots are competent and

will take the right runway.

• Improvement to the SOP (the addition of detail)

• Critical mistake so

utilized standard callout

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AS AN INDUSTRY WE…

Need to create, retain, transfer

and modify the frontline behavior

through SOPs and checklists. We

need organizational learning!

Then your human error rate will

fall by 100 to 1000 times less.

THANK YOU!

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SWISS CHEESE – JAMES REASON

Organizational

Influences

Hazard

Mishap

and/or Injury

!

!

Organizational - level

Person-level

Failed or

Absent Defenses

Latent Failures

Supervision

Preconditions

Unsafe Acts

Active Failures

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Standardization is the keeper of procedures to…

▪ Achieve consistency in execution (Control procedural drift)

▪ Share expectations on how to conduct routine work

▪ Improve corporate learning curve (Organizational Lessons Learned)

▪ Reduce re-work due to human error (Reduce waste)

▪ Increase proficiency (Measured through KPIs)

▪ Prepare for growth (Training, Efficiency, Scalable)