*3.1. Framework*

Figure 3 presents a framework that offers an insight into how the present study applied the research inputs and produced the results.

**Figure 3.** Research study framework.

The top layer reflects the five themes that formed the basis for the data gathering template. These themes were developed through an iterative process of conducting focus group sessions with two themes emerging, i.e., root cause and reporting. Concurrently, a systematic literature review was performed using NVivo software to assist the researchers manage over 1000 screened publications. Following a thematic analysis of the data, three main themes (Appendix B) emerged from a final cache of 18 publications, i.e., learning from incidents, precursors and just culture. The five themes informed the structure of a data gathering instrument that supported 34 semi-structured interviews in the continuing airworthiness segmen<sup>t</sup> of the industry. Following transcription, the data were uploaded to NVivo where they were thematically analyzed using the Braun and Clarke [47] framework. The outputs from the thematic analysis distilled the interview analysis into three main outputs, i.e., learning from incidents, learning process and learning product. The lower tier represents the elements the themes were comprised of and the findings are presented under these headings (Table 5).

> **Table 5.** Summary of results. 1 Learning from incidents (LFI) is a safety managemen<sup>t</sup> activity with a desired outcome of preventing unwelcome event recurrence.<sup>2</sup> A learning process facilitates a change in knowledge and behavior intended to support LFI.<sup>3</sup> Safety related information arising from the LFI process.


### 3.1.1. Learning form incidents—Acquiring, Processing and Storing Data

Incident reporting is accepted as a worthwhile activity amongs<sup>t</sup> those participating in the study. This is based on the collective notion that the initiative raises awareness of incidents and potential hazards and can therefore help prevent event recurrence. The authors recognize that awareness is an important component of learning from incidents. Situations do arise where due to lack of report data, it is questionable if all the necessary reports are being submitted as required. Amongst the constraints to making a report are perceived production pressures and the potential embarrassment that could arise from making a mistake and highlighting it [5]. There are just culture concerns amongs<sup>t</sup> some sta ff because they do not always know what the impact for them personally will be if they submit an incident report [44].

A dedicated focal point in organizations is essential for the systematic managemen<sup>t</sup> of reported incidents. Where this discipline is applied, the process owner is responsible for highlighting reported issues and raising the necessary awareness amongs<sup>t</sup> operational sta ff. Once an incident is acquired through the e fforts of a reporting system, some form of processing and analysis is necessary. The availability of adequate resources for determining causation and implementing measures to prevent recurrence was identified as a primary point of concern. Perceived premature closure of reports was also highlighted amongs<sup>t</sup> participants. There was a call for improved accountability and transparency on decisions relating to some closure actions. Respondents associate the practice of applying commercial key performance indicators to safety managemen<sup>t</sup> as shallow e fforts are sometimes made by organizations to expeditiously and prematurely close reports on occasion. Incident reporting and safety managemen<sup>t</sup> initiatives have been in existence for some time. Large repositories of associated safety data are stored in many organizations. Although entities are mandated to inform key stakeholders, there is a strong opinion amongs<sup>t</sup> some participants that the data repositories could be aggregated and put to better use in support of learning amongs<sup>t</sup> all operators.

### 3.1.2. Learning Process—Single-Loop, Double-Loop and Deutero Learning

The interview data confirms that safety is a primary underpinning value in the organizations that participated in the study. The release of a safe product, i.e., an aircraft or component, is a formative pursuit and measure of learning. In organizational environments where a "find and fix" ethos may prevail, single-loop learning [11] is evident in the examples presented.

A desired outcome of double-loop learning [11] is often witnessed for example through the adjustment of environmental, behavioral and procedural norms. Instances of double-loop learning can be evident following unsuccessful attempts through single-loop learning where causation is then adequately understood and actioned. Continuation (mandatory in-service) training was considered by study participants as an e ffective mechanism that enables double-loop learning. During the study, it was apparent that single and double learning loops are recognized amongs<sup>t</sup> many participants as having di ffering capabilities in terms of delivering an e ffective learning product. However, there was no evidence of formal reviews of single and double-loop learning being performed within the participants' organizations. Although deutero-learning [11,55] may be considered as a natural extension of other levels of learning, the concept did not feature strongly amongs<sup>t</sup> the participants. A review of the EU1321/2014 [6] implementing requirements confirms an absence of any mandatory requirement to review learning processes.

### 3.1.3. Learning Product—E ffectiveness and Types of Knowledge

Continuation training is a mandated European requirement [6] for all aircraft maintenance and continuing airworthiness managemen<sup>t</sup> organizations. It is a product as well as a medium for imparting learning from incidents and safety related hazards. It was identified during the study that the learning product is shared amongs<sup>t</sup> sta ff through three primary means of distribution: formally delivered

continuation training, tool-box talks and safety briefings and electronic, paper, notice board and "read and sign" safety publications. The study suggests a learning product can arise as a result of an output from an incident lifecycle. Feedback from submitted occurrences to stakeholders varies from very good to poor. Cost is seen as a major consideration in some of the participating organizations when planning continuation training delivery. Although computer-based training is being considered in some companies as a viable option to class-room delivery, concerns are evident in respect of e ffectiveness of this medium in its current form. Bedwell and Salas [56] sugges<sup>t</sup> computer-based training (CBT) can be used as a methodology for providing, "*systematic, structured learning; a useful tool when properly designed*".

The perceived overburdening of operational sta ff with complex learning products and excessive cognitive loads was recorded as an impediment to learning during the study. Participants suggested this can arise from poorly designed training syllabi delivered during periods of high operational activity.

Four knowledge types were identified and relate to: conceptual, dispositional, procedural and locative knowledge forms [57]. One of the key objectives of learning from incidents is to identify the type of knowledge needed to prevent an issue recurring. When a reportable issue, for example, is discovered, the submitted report will identify "what" happened. Subsequent follow up will set out to determine "why" the issue occurred. The guiding principles of "how" to perform the task or operation are often contained in procedures or data particular to the task. The information contained in procedures will enable a person to utilize other forms of knowledge. Prevailing safety culture within an organization will have an impact on learning from incidents. If a strong commercial/production culture exists, this may have an impact on, for example, the depth and breadth of learning from incidents within the company. Induction and initial training are important when accessing information for new sta ff. Accident data repositories contain well-documented human factor-related examples often relating to access to approved data and consequently resulting in potentially preventable incidents. Examining the limitations of each type of knowledge when continuation training programs are being developed was flagged as important by some participants. During the study, no discernible di fferences were recorded in how the types of knowledge were di fferentiated in participant organizations. A review of the EU 1321/2014 [6] human factors syllabus requirements did not highlight a need to appreciate or account for these human centered limitations when designing and delivering training lessons. Improved regulatory guidance on the design of e ffective human factor related material should therefore be developed. Information on how training should be structured in order to appreciate types of knowledge and capitalize on it as a minimum are required to ensure the most e fficacious outcome from incident-related training.
