How We Can Learn From Incidents
lunes, 28 de marzo de 2016
https://www.youtube.com/watch?v=NaXE5pbLI0E
You are having coffee with some of your colleagues discussing and laughing about a mistake another colleague of yours has recently made. You say: "Did you already hear the latest story?" "How could he have done that...?!" "I mean okay, NO BLAME, but this was really too stupid" Think for a minute, do you have the tendency to react that way? you still think: "If only he had reacted in a different way. And you are convince YOU would have reacted in a different way...." ?Read more...
Whilst it is easy to point the finger at somebody else, what if - one day -- the finger is pointed at you...? Would you not want to explain what really happened? To be understood? Because you did your best, it was logic to do it that way? You were right with it!
The goal of a Swiss Air Force flight safety investigations is to do precisely that: to find out what really happened and Why it made sense at that moment, rather than pointing the finger at any individual. This is what we mean when we say we are committed to a "Learning culture".
Think about it: The Swiss Air Force is a high risk organization: hundreds of employees ensure high risk missions during 24 hours, 365 days: As a worker in the planning desk, on the tarmac, in a truck or as a pilot in the cockpit. All of us do the very best we can to fulfill mission.
However, we don't always succeed.
Why? This is what the Swiss Air Force flight safety investigation helps us to find out.
Contrary to a legal investigation initiated by the Military Justice, the purpose of an Safety investigation is NOT to find the guilty, but to understand why it made sense to you and to learn from your view to make the system safer.
What exactly do we mean by that?
Lesson 1: Don't put the blame on individuals, ask questions to understand If people get blamed for their mistakes, the only thing one achieves is that people will keep their knowledge about mistakes, safety gaps or dangerous situations for themselves. Ask "why?" like a mantra to get deeper and deeper to the cause, to put yourself into the actor's shoes and to understand, why the event had been happen.
Lesson 2: Learn from experiences and make your job safer Mistakes or incidents can be seen as free lessons. If we fail to learn from them, other colleagues will fall into the same traps because the holes/safety gaps are still there. Please support the management's safety effort and ask for a Flight Safety Investigation to help you formulate a report whenever you experience an event that you think offers an opportunity to learn.
And remember: the goal of a Flight Safety Investigation is never to stop the Air Forces from flying! The goal of a Flight Safety Investigation is to enable that the operations can take place with an improved margin of safety and to safe all the available assets we have: To safe you!
You can make a difference! You're the expert! Please send this video to anyone within the Swiss Air Forces you know.
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