2025 Community of Human and Organizational Learning 31st Annual Conference

The Learning and Improvement Team (LIT), developed in partnership between American Airlines (AA) and the Allied Pilots Association (APA), is a blossoming safety program designed to learn what makes flight operations successful. Aviation safety has traditionally focused on accidents and unwanted outcomes but as the industry has become much safer those events have become fewer and far between, thus providing fewer opportunities to learn. LIT is designed to capture data on what goes well and why in AA flight operations. Because the Learning and Improvement Team uses relatively new safety science approaches including Safety-II and Safety Differently, it has faced some challenges in its development and implementation. Awareness of the program and a general understanding of its capabilities have been slow to develop but are greatly improving. Additionally, data analysis and presentation have proved challenging because the data collected looks unconventional when compared to existing data sources. Despite these challenges, the program has steadily expanded and found a place of permanence within the airline’s Safety Management System (SMS). By LIT facilitating the ability to look at all operations, not just the negative outcomes, American Airlines and its pilots can be better positioned to learn, both as individuals and as an organization.

What do Wildland Fire Fighters and Software Engineers have in common?
They’ve both taken the position that the most important thing after an incident is LEARNING. What may be shocking to some, is they both believe that the learning they produce is more important than corrective actions. In fact, corrective actions are not required – or even desired – for some incidents.
In this session, leaders from both communities will share how they learn from incidents. They will explore commonalities in their practices, what is most important for learning, and what they do differently and why.
“We love incidents. Well, love is a strong word. But incidents don't have to be a terrible experience. The community we started has spent a lot of time understanding just how much value you can get out of incidents, and how they can be used as a way to disseminate expertise throughout the organization.” Learning From Incidents Community of Practice (Software)

• Persephone Whelan led the team that recently revised Wildland fire Learning from Unexpected Outcomes and Learning Review process.
• Joe Harris has spent the last two years as the chair of the Response Protocol steering committee which is in charge of training and implementation of the accident review processes within the wildland fire community.
• Thai Wood is part of the Software Learning from Incidents Community of Practice.

We’ve come a long way since the pioneer days of Human Performance. All along the way, we’ve used systems learning, powered by systems thinking, to forge better approaches to making complex things work. Today, we will explore how we can unpack some of this collective ‘tacit’ knowledge about our systems to reduce the number of shiny objects on the safety net we maintain for our expert workforce, making it less distracting and stronger. This presentation will explore the systems, systems thinking, and systems learning that sit outside of Jens Rassmussen’s Dynamic Safety Model, functionally turning it into a Dynamic Operations Model.

Key concepts
•    Collective mental models (static) enabling collective mental pictures (dynamic)
•    How Organizations help to reduce the gradients in Rasmussen’s model
•    Understanding how we are succeeding – deep technical understanding
•    Hidden feedback loops - conversations
•    Loosening the reins – designing imperfect systems, on purpose
•    Thinking like an operator – staying light on our feet
•    Expert intuition
•    Supporting experts – weaving and maintaining the safety net
•    Influencing leaders – implementing strategies for servant leadership

Accountability is the foundation of the relationship between a leader, the team and individual team members. Creating accountability is fundamental and ongoing leadership practice. To hold someone accountable after a failure is to reexamine the accountability relationship and perhaps restructure it. That blame, an ego-defense to fear, anger, or shame, has been equated with accountability is simply evidence of a failure of leadership in organizations. This talk will address what effective accountability looks like and how to create it. It will also discuss why blame arises, from a psychological perspective, and how to manage it. The goal of the talk is to help you go back to your organization and break up accountability and blame for good.

We have choices:
Blame and Punish
Learn and Improve

• The Worker is NOT the problem to be fixed.  The Worker is the problem solver.
• We make our organizations safer by making our systems more robust and resilient.
• Therefore, We try not to tell our workers what to do - We ask workers what they need to manage safe work.
• We Define Safety as the Presence of capacity.