Why a Course on Lessons Learned?

Many major accidents have been shown to follow one or more previous incidents that were not acted upon because someone was unaware of the significance of what they observed. Often this was because they failed to understand the event at the system level rather than at the component or subsystem level. One reason for this failure may be that engineers involved were unaware of the existence of critical relevant information, i.e., lessons learned.

This lack of awareness is likely the result of inadequate processes to ensure that the lessons learned from specific experiences are captured permanently and made readily available to the aviation industry. This failure to capture and disseminate lessons learned has allowed airplane accidents to occur for causes similar to those of past accidents.

Increasing our workforce understanding of lessons learned is an important building block to preventing repeat accidents (due to similar cause), and to improving our system safety awareness.

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