**5. Discussion**

Recalling the causal factors attributed to the featured occurrence reports in the paragraphs above, it is easy to appreciate their relationships with the 'Dirty Dozen' example of human factor elements. For example, lack of resources can be a major constraint when it comes to providing adequate levels of appropriately qualified competent staff. Pressures exerted upon staff in a dynamic industry sector to absorb additional workload can of course have a potentially detrimental effect on safe operations. Competent and available supervision of maintenance and inspection staff is a core requirement of a quality mission in aircraft maintenance and continuing airworthiness managemen<sup>t</sup> operations. In many regions the maintenance requirements (e.g., EU regulation 1321/2014 [4]) stipulate a process whereby all staff must meet the qualification criteria and be deemed competent before unaccompanied work can take place. For the purpose of the discussion, key elements of the incident cycle components are examined through pertinent elements identified during the analysis. The iterative approach suggested during the managemen<sup>t</sup> of the incident information is supported by the context outlined below. Understanding the relevance of each of the sections is intended to support more effective learning outcomes. The following paragraphs discuss the incident cycle from the perspective of developing a sound learning product.

### *5.1. Acquiring, Processing and Storing Incident Data*

According to Garvin [34], a clear definition of learning has proven to be elusive over the years. Garvin suggests '*a learning organization is an organization skilled at creating, acquiring and transferring knowledge and at modifying its behaviour to reflect new knowledge and insights*'. Figure 1 illustrates the evolution of an incident as it is managed through its cycle. The incident/occurrence will need to be detected if it is to possess any potential for learning. Acquiring information in support of learning is one of the key actions. Such learning material originates from compliance audits, amended regulatory requirements, best practice, and incidents and occurrence reports. Within the greater area of aircraft maintenance and continuing airworthiness management, details of incidents and occurrences tend to be reported soon after an event. Reporting requirements are normally timebound (i.e., 72 h). Most organisations endeavour to notify the necessary stakeholders as soon as possible, often by telephone in the first instance. As many airline staff are employed on a shift work basis, the window of 72 h is useful in support of administering the

reporting function. It is not unusual to have numerous points of contact for reporting within organisations. However, reporting generally follows a consistent route regardless of who the initial point of contact is. Some organisations appear to empower and encourage the submission of reports by any individual. Other organisations appear to endorse reporting through a 'chain of command'. Regardless of the chosen initial reporting route input, all reports are progressed to a 'gate-keeper' within an organisation. The people responsible initially for examining the validity and completeness of submitted reports often hold a key position in either the quality assurance, technical services or maintenance departments. Generally, there is a strong awareness of the need to report incidents and occurrences classified as mandatory. There may be numerous motivational reasons to report, such as ethical, safety, compliance with regulatory requirements and best practice for example. Those submitting reports embrace mandatory reporting as an obligation underpinned by the cultural norms of aircraft maintenance and continuing airworthiness management. When an issue is discovered, it is progressed through the reporting system regardless of its status. Many organisations welcome all reports including non-mandatory events that are highlighted through voluntary reporting streams. They evidently see value in including them in their analysis of events and the subsequent learning opportunities the reports may o ffer.

### *5.2. Single, Double and Triple-Loop Learning*

From an organisational point of view, single-loop learning can be experienced when an error is detected and corrected but little else changes, Argyris and Schön [19] (p. 18). In aircraft line maintenance environments where a 'find and fix' ethos prevails, single-loop learning is often evident. It is not unusual for technical issues to befall an aircraft's departure time. Such pressure points often associated with fulfilling contractual obligations may have a negative impact on the potential for learning from a related event. In such cases, if issue arises the matter may be resolved without any further recorded action. Because of the terse nature of the experience for an individual concerned, the opportunity for further learning may not extended beyond the single loop. Argyris and Schön [19] (p. 21) and Lukic et al. [35] pro ffer double-loop learning as learning that takes place and results in organisational norms and theory in use being altered. Presently, aircraft certifying, and support sta ff are obliged to continuously preserve an adequate understanding of the aircraft being maintained and managed along with associated regulations and procedures. A desired outcome of double-loop learning is often witnessed for example through the adjustment of environmental, behavioural and procedural norms. Instances of double-loop learning can be evident following unsuccessful attempts through single-loop learning. In-service continuation training is an e ffective enabler that is capable of supporting double-loop learning. Organisations are also required by EU 1321/2014 [4] to establish and maintain a continuation training programme for sta ff. A primary pillar of continuation training syllabi is the use of incidents and occurrences as lesson content for influencing organisational norms and behaviour in support of preventing recurrence of incidents and occurrences. Deutero-learning (triple-loop) relates to when members of an organisation reflect upon previous learning and sets about to improve how the organisation can refine and improve the process of learning from events, Argyris and Schön [19] (p. 29), Bateson [36]. This could also be stated as learning how to learn by seeking to improve single and double loop learning. Although deutero-learning may be considered as a natural extension of other levels of learning, the concept does not feature as a requirement in aircraft maintenance and continuing airworthiness managemen<sup>t</sup> regulatory codes.
