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Launched Aug 26 1996.

 

This page lists documentation of investigation-oriented lessons learning system research by
Ludwig Benner, William D Carey and Ira J Rimson since 2006.
The documentation thus far includes papers, slide presentations,
a slide script, and two videos. The work is ongoing.

Contents

  1. ESReDA 33 Paper: Benner, L., Accident Data for the Semantic Web, ESReDA 33 Seminar, Ispra IT, November 2007
      - - -   Noteworthy Insights - - - Abstract - - -    Document    - - -

  2. ESReDAd 33 Slide presentation: Benner, L., Accident Data for the Semantic Web, ESReDA 33 Seminar, Ispra IT, November 2007
    - - -    Noteworthy Insights - - -    Abstract - - -    Document - - -   

  3. SSTS 08 Tutorial (Slides): Benner, L. and Carey, W.D., Investigation Lessons Learning System Flaws and Fixes, Washington DC System Safety Training Seminar, La Plata MD, June 25 2008
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  4. ESReDA 36 Paper: Benner, L., Lessons Learning System Attributes: An Analysis, ESReDA 36 Seminar, Coimbra PT June 2009
    - - -   Noteworthy Insights - - -    Abstract - - -     Document - - -   

  5. ESReDA 36 Slide presentation: Benner, L. Lessons Learning System Attributes: An Analysis, ESReDA 36 Seminar, Coimbra PT June 2009
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  6. ISSC 09 Tutorial (Slides): Benner, L. and Carey, W.D., Lessons Learning System Analysis and Assessment, International System Safety Conference, Huntsville, AL August 4 2009 (Slides)
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  7. ISSC 09 Tutorial (Video): Benner, L. and Carey, W.D., Lessons Learning System Analysis and Assessment, International System Safety Conference, Huntsville, AL August 4 2009
    Request DVD disk from Ludwig Benner e-mail requests to iprr.org - - - free to researchers,
    - - -    Noteworthy Insights - - -    Abstract - - -   

  8. ISASI 09 Paper: Benner, L. and Rimson, I.J., Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities, International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  9. ISASI 09 Slide presentation: Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities, International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009 (slides)
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  10. ISASI 09 Slide Presentation Script: Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  11. ISASI 09 Presentation HD Video: Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities, International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009
    Request DVD disk from Ludwig Benner; e-mail requests to iprr.org - - - free to researchers

  12. HPRCT 2010 Paper: Benner, L.,Transforming Experience into Performance Improvement,16th Annual Human Perfirmance Root Cause Trending Conference, Baltimore MD June 21-25 2010
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   

  13. HPRCT 2010 Slide Presentation with notes (.pdf): Benner, L., Transforming Experience into Performance Improvement,16th Annual Human Perfirmance Root Cause Trending Conference, Baltimore MD June 21-25 2010
    - - -    Noteworthy Insights - - -    Abstract - - -     Document - - -   


Noteworthy Insights Introduced

1. ESReDA 33 paper:
  • redefines current lessons learned implementation impediments
  • showed breadth of organizations struggling with lessons learned practices
  • recasts investigation goal as supporting universal distribution of accident behaviorial interactions for prevention action to all potential users
  • describes challenges to and opportunities for achieving that goal
  • shifts analytical focus from lessons learned to a lessons learning system serving end users
  • defines essential components of comprehensive lessons learning system
  • shows investigations as part of learning organization's knowledge source for lessons to learn
  • proposes focus on dynamic behavior of systems
  • defines structure for investigation input data to enable investigation outputs that are congruent with end users needs
  • proposes organizing to address challenges and opportunities for improvement
  • provides example of alternative web-friendly system for improving performance, including
    • new goals and input-output framework for investigations
    • new investigation behavioral input data structure to support machine interoperability
    • non-causal coupling of investigation behavioral data into event sets and arrays
    • behavioral interaction set arrays as investigation quality assurance tool
    • structure for documenting lessons to be disseminated and learned

Noteworthy Insights Introduced

2. ESReDA33 slides 2007
  • Illustrates alternative web friendly lessons learning data structures and procedures, including behavioral input-output data sets.

Noteworthy Insights Introduced

3. SSTS Tutorial 2008
  • models current generic lessons learned cycle
  • defines obstacles to optimization of lessons learned practices
  • illustrates difference between static and dynamic mishap data inputs
  • introduces lessons learned latency, assimilability concept
  • suggests application of OODA loop concepts to reduce latency
  • illustrates language for dynamic accident process description
  • suggests dissemination via social networking approach
  • urges end users to demand lessons data congruent with their needs from investigators

Noteworthy Insights Introduced

4. ESReDA36 paper 2009
  • presents systems analysis of lessons learned practices and functions
  • defines synthesized model and attributes of current lessons learned practices
  • defines components and attributes of comprehensive lessons learning system from lesson users and developers perspectives
  • proposes listing lessons explicitly in investigation reports

  • begins to identify strategic decisions and their effects on lessons learning practices, defines functions and attributes of present investigation practices that impede learning, and proposes 26 attributes of a lessons learning system needed to achieve improved learning from mishaps.

Noteworthy Insights Introduced

5. ESReDA36 slide presentation 2009
  • expands on insights offered in paper

Noteworthy Insights Introduced

6. ISSC 2009 Tutorial Slides
  • provides criteria for self-assessment of lessons learning practices that safety and risk analysts encounter
  • offers assessment criteria
  • how to use criteria to get what they need.

Noteworthy Insights Introduced

7. ISSC 2009 Tutorial Video
  • Discussions add to insights about present practices and options available
2 1/2 hour video of tutorial by Benner, and Carey on Lessons Learning System Analysis and Assessment

Noteworthy Insights Introduced

8. ISASI 2009 paper
  • introduces and defines retrocursors for investigators
  • describes roles of retrocursors and behavior sets
  • claims accident causation models are archaic
  • defines attributes for lessons to be learned
  • proposes system improvement actions

Noteworthy Insights Introduced

9. ISASI 2009 presentation
  • Ties "retrocursor" accidents to accident prevention
  • defines accident prevention as changing behavior sets
  • defines new metric for prevention effectiveness
  • defines new metric for lessons learning system effectiveness
  • contrasts present lessons learning system design strategies with new strategies
  • offers opens source software library to investigation organizations to accelerate evolution of structured investigation behavioral inputs

Noteworthy Insights Introduced

10. ISASI 2009 Script with slides
  • current lessons learned practices are not complete systems
  • establishes 4 goals for success lessons learning system for investigators
  • states what lessons learning system should accomplish in terms of changed behavior patterns.
  • states insights gained after paper submission, including criticality of proper investigation input data structure, changes being driven by social networking developments, and opportunities offered by digitized data sources in aviation.

Noteworthy Insights Introduced

11. ISASI Video highlights
  • 20 minute video of oral presentation accompanying slides.

    Insights are described in Script above

    Request DVD disk from Ludwig Benner; e-mail requests to iprr.org - - - free to researchers,

Noteworthy Insights Introduced

12. HPRCT 2010 Paper highlights
  • experience generates data for improving performance
  • goal is shortest data path from exprience to improvement
  • data documentation dependency pyramid showing documentation of source data into building blocks affects all that follows
  • structuring integrated standardized building block, analysis and lessons to be learned
  • lesson should have behavor sets structure

Noteworthy Insights Introduced

13. HPRCT slides with notes (.pdf) highlights
  • remember latency metric
  • shows how to structure standardized building blocks, analysis and lessons to learn
  • displays behavior set development, overlay method
  • offers incremental implementation plan
  • summarizes ponts to remember




Research continues to explore the nature and role of concepts, strategies and strategic decisions in the design of investigations and related lessons learning system improvements.