Learning Loop
What operators notice in the field — oddities, near-misses, workarounds — is easy to report, reaches the people who can change the machine, and visibly leads to changes. This is how After feeds back into Before.
Herald of Free Enterprise Draft
March 6, 1987 · Zeebrugge, Belgium
Just after 6 p.m., the roll-on/roll-off ferry left the inner harbor at Zeebrugge with her bow doors open. The crewman responsible for closing them was asleep in his cabin, and from the wheelhouse the captain couldn't see the doors and had no indicator to tell him. Water flooded the car deck and the ship capsized within minutes, less than a mile outside the harbor. 193 people died. The company had been told. Its ferries had sailed with doors open before, and in 1985 a captain asked for indicator lights on the bridge. The request was dismissed. After the disaster, indicator lights on the bridge became a legal requirement.2
Anti-pattern: Reported and Forgotten Draft
Masters across the fleet knew ships had sailed with their doors open, and one put it in writing with a fix attached. The memo reached management and stopped there. Nobody who could change the ships acted on it, and nobody who reported it heard back.
Learning Loop
Therefore: Make reporting cheaper than staying silent, route every report to someone who can change the machine, the procedure or the training, and show the reporter what changed.
DraftSimplified illustration.
Without
Bow doors
- Ferry · Bridge
- Sailing 1
- Bow doors
- no indicator
After departure, the deck crew
found the bow doors still open.
They closed them at sea.
Report it, then take the next sailing.
With the pattern
Bow doors
- Ferry · Bridge
- Sailing 1
- Bow doors
- no indicator
After departure, the deck crew
found the bow doors still open.
They closed them at sea.
One tap, and no blame attached.
The loop closes where the reporter can see it.
The mechanism
operator notices → the loop closes visibly
- 01Operator noticesAn oddity, a near-miss, a workaround
- 02Reporting is easyLow effort, and no blame attached
- 03 · Key momentIt reaches who can change itEngineering and training, not just the file
- 04Something changesThe machine, the procedure or the training
- 05The loop closes visiblyReporters can see what their report changed
On this page
Design considerations Draft
- Make reporting cost less than silence. One step, from where the work happens, with no blame.4
- Route to someone who can change it. A report that only reaches a file is a record, not a loop.
- Count repeats, not just reports. Group similar reports so a pattern shows up as one.
- Close the loop visibly. Show reporters what changed, or why nothing did. People stop reporting when reports vanish.4
- Treat workarounds as reports. A workaround means the design failed quietly.
In the field Draft
■ Without it · Maritime: Herald of Free Enterprise (1987). Requests for bridge door indicators were dismissed before the capsizing.2
■ Without it · Aviation: Air France 447. Repeated unreliable-airspeed events were reported, but the feedback never reached training.3 It is the opening story on Graceful Degradation.
● Applies the pattern · Aviation: NASA ASRS. Confidential, non-punitive reporting, analyzed and published back to pilots through CALLBACK.4
Related patterns
- Complements · 02The Glass BoxLogged overrides are the richest input this loop has: repeated disagreement in the same situation is the clearest sign the machine is wrong.
- Complements · 08Provenance LogThe log is the record of what the machine did; the loop is what carries what the operator noticed. Neither substitutes for the other, and an investigation usually needs both.
- Complements · 10Explainable FaultAn unnamed fault cannot feed back. Without the alert, the JT610 crew could not document the faulty sensor, so it was not available to help maintenance. JT610 is now an In the field entry on this page rather than its opening.
Sources
The hard part is not intake, it is the two ends. At the front, reporting has to cost less than silence, which is why the ASRS is confidential, non-punitive and sits with NASA rather than with the authority that could act on what it reads.4 At the back, something has to visibly change, and the people filing reports have to be able to see that it did. A loop whose far end is invisible is indistinguishable from a suggestion box, and it gets used like one.
Air France's A330/A340 fleet filed nine unreliable-airspeed reports between May 2008 and March 2009, and after AF447 the airline went back through recorded flight parameters and found six more incidents that had never been reported at all.3 The BEA's causal factors name the feedback mechanisms directly: they made it impossible to identify that crews were repeatedly not applying the procedure, and to remedy it.3
An indicator light was never the hard part. The hard part was getting the request to someone who could install one, and showing the masters it had happened.