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‘Lessons learned’ is validated working knowledge derived from successes or failures that, when reused, can significantly impact on organisation’s processes. (Secchi, 1999)
To make available to the organisation’s personnel the knowledge gained from experience and promote its use for the improvement of safety of services provided.
To keep the risks at an acceptable level with the increasing volume and complexity of operational activities, aviation service providers must adopt and apply extensively proactive safety management practices. Lesson dissemination is one of the attributes of the proactive and modern approach to safety management. It is the SMS element that encompasses the sharing of best practices utilised and safety lessons learned through the active exchange of safety information inside and outside organisations and States.
Lesson dissemination is enabled by Safety Communication which according to International Civil Aviation Organisation (ICAO) is an essential element of safety promotion. Proper safety communication will guarantee improved safety awareness among the organisation’s personnel, it will convey safety critical information, and explains why particular safety actions are taken and why safety procedures are introduced or changed.
Different sources of useful lessons can be identified in a SMS. The outcome of safety occurrence investigation is the most important one, since it provides lessons on problems, which have already contributed to actual occurrences in flight operations. Safety surveys and safety monitoring and analysis programmes, such as Line Operations Safety Audit (LOSA) and Normal Operations Safety Survey (NOSS) may also provide important lessons, since they examine systems operating under normal conditions to identify weaknesses that have not yet been seen to contribute directly or indirectly to an occurrence.
As a minimum, lessons should be disseminated to all the concerned staff in the units with involvement or interest in the issue. According to Commission Implementing Regulation (EU) No 1035/2011 of 17 October 2011 laying down common requirements for the provision of air navigation services the lessons arising from safety occurrence investigations and other safety activities shall be disseminated within the organisation at management and operational levels. This will promote the facilitation of the personnel involvement in proposing solutions to operational hazards and will enable the staff to suggest different perspectives of methods for safety improvement.Where appropriate, information can also be passed to safety regulatory bodies or international organisations.
The EUROCONTROL advisory material to ESARR3 - Use of safety management systems by ATM service providers gives generic guidance on the processes to be established for lesson dissemination, which include:
- Collection of lessons - a systematic process to collect lessons arising from safety occurrence investigations, and other safety activities (including, but not limited to safety surveys and safety monitoring) in a manner which ensures that interrelationships can be detected. Lessons from external sources should also be incorporated into the process.
- Dissemination of lessons to personnel - lessons learned are passed to all concerned staff. Whenever possible, various dissemination methods should be used, such as: presentations, reports, audio-visual tools, safety publications etc.
- Incorporation into training activities - relevant information from lessons learned should be used to improve the training programmes and contents.
- ICAO Doc 9859 - Safety Management Manual, Third Edition - 2013;
- ICAO Integrated Safety Management website;
- Commission Implementing Regulation (EU) No 1035/2011 of 17 October 2011 laying down common requirements for the provision of air navigation services and amending Regulations (EC) No 482/2008 and (EU) No 691/2010;
- Eurocontrol Safety Regulatory Requirement - ESARR3, Use of Safety Management Systems by ATM Service Providers;
- ESARR Advisory Material/Guidance Document - EAM3/GUI3 ESARR3 and Related Safety Oversight.
- Lessons Learned from Belgocontrol Power Failure Belgocontrol, 2017