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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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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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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.
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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)