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Sustainability
Sustainability, organizational and lessons
learning, and lessons learned learned
from aviation
77
John Pourdehnad
University of Pennsylvania, Philadelphia, Pennsylvania, USA, and
Peter A.C. Smith
The Leadership Alliance, Inc., Brechin, Canada

Abstract
Purpose While the importance of organizational learning for sustainability has been stressed by a
number of authors in the literature, the practicalities of how organizational leaders might foster such
learning are seldom treated. This paper seeks to demonstrate that there is much that could be learned
from the aviation industry about organizational learning practice that could be gainfully applied by
organizations in attempting to address the demands of triple bottom line sustainability.
Design/methodology/approach The exemplary safety record of the US commercial aviation
industry is explored in this paper, and the principal functions of its underlying learning and adaptive
system are reviewed. Generalized application of such a learning and adaptive system in an
organization operating according to triple bottom line sustainability principles is described.
Findings Through the interaction of various functional components described in the paper, the
commercial aviation industry has created a learning and adaptation support system that has
significantly and effectively increased air travel safety. The characteristics of such a learning and
adaptive system can be employed by any organization to vastly improve its performance as it pursues
triple bottom line sustainability.
Originality/value The learning and adaptive system approach presented expands the steps of
understanding, creating and delivering triple bottom line sustainability by changing internal
processes, organizational learning, and employee mindsets.
Keywords Triple bottom line sustainability, Organizational learning, Practical application, Value added,
Aviation industry, Sustainable development, Learning organizations
Paper type Conceptual paper

1. Introduction
In a recent paper, Wasdell (2011) spelled out practical implications for the development
and application of organizational learning in regard to the decision-making involved in
climate change negotiation at international levels. Wasdell (2011, p. 19) went on to infer
that to make progress on sustainability at any level, international, national, or local,
We face the daunting task of developing and applying processes of organizational
learning in such a way that the skills can be embedded fractally in all levels of
institutional life. Although in the early part of the decade the importance of
organizational learning for sustainability has been stressed by a number of authors
(Nattrass and Altomare, 1999; Senge and Carstedt, 2001; Molnar and Mulvihill, 2002;
Jamali, 2006; Smith and Sharicz, 2011), Fenwick (2007) is one of the few to address the The Learning Organization
Vol. 19 No. 1, 2012
practicalities of how organizational leaders might foster such learning. pp. 77-86
In this paper, sustainability is treated as triple bottom line (TBL) sustainability, and q Emerald Group Publishing Limited
0969-6474
defined as the result of the activities of an organization voluntary or governed by law, DOI 10.1108/09696471211190374
TLO that demonstrate the ability of the organization to maintain viable its business
19,1 operations (including financial viability as appropriate) whilst not negatively impacting
any social or ecological systems (Smith and Sharicz, 2011, pp. 73-4). Bearing in mind
this definition, the authors in this paper have accepted the challenge identified by
Wasdell (2011) and quoted above; in the following sections a relevant proven practical
organizational learning approach to embed the necessary skills fractally in all levels of
78 institutional life is described. This practical organizational learning approach is
founded on research related to optimal general organizational decision-making presented
a decade ago by Pourdehnad (2000)m but which is timeless in its relevancy.
It is clear from the above definition of TBL sustainability, and confirmed from
research such as that of Smith and Sharicz (2011), that organizational learning in this
TBL context must try to address the systemic implications of harmonizing the
demands of the TBL definition, whilst at the same time contending with the dynamic
complexity of our global reality. In addition the organizational learning approach must
redress the Titanic syndrome (Smith and Saint-Onge, 1996) that still grips the minds of
so many leaders today, preventing them from taking timely remedial action. No small
achievement!
Most organizations today would agree that they face highly complex hostile
operational environments, and yet safeguarding against even the most devastating
errors is seldom pursued in earnest (Drew and Smith, 1995). In the following sections the
authors describe the organizational learning experience of a business sector where for
many years organizations have faced and overcome systemic, complex, mind-set related
issues in hostile contexts by embedding the necessary skills fractally in all levels of
institutional life. This business sector is US commercial aviation, and the outstanding
safety record of this industry (Wikipedia, 2011) convincingly vouches for the success of
how organizational learning may be applied in resolution of such multifaceted issues.
Throughout this paper, the authors adopt the definition of organizational learning
as the detection and correction of error, whereby an error is defined as the
discrepancy between what members in an organizational context aspire to achieve and
what they actually achieve (Van Grinsven and Visser, 2011, p. 379; Argyris and Schon,
1978; March and Olsen, 1975).

2. US commercial aviation system

2.1 Background
Historical data on airline safety shows that in the early days of commercial aviation,
airline fatality rates were approximately 1,500 times higher than those of railroads and
900 times higher than those of bus lines (Comptons Encyclopedia, 2000). Today it is
commonly known that air travel is safer, in terms of passenger miles, than travel by
automobile, bus, or railroad. According to Wikipedia (2011) when it comes to a
question about risks associated with a particular long-range travel from one city to
another, the most suitable comparative statistic is deaths per billion
passenger-kilometers, thus giving a reason to name air travel as the safest form of
long-range transportation.
Clearly, the commercial aviation industry is doing something right about safety.
Indeed, its progress has been impressive. It exemplifies a successful learning and
adaptive (L&A) system. In order to understand its accomplishment, it is necessary to
understand the principal functions of its system.
 The commercial aviation system, in addition to its operating environment, consists Sustainability
of three major components that interact continuously. According to Krause (1996, and lessons
pp. x-v), these are:
(1) software (all the regulations, SOPs, policies, manuals, checklists, maps,
learned
performance charts, tables and graphs);
(2) hardware (the aircraft itself and its supporting system); and
79
(3) liveware (pilots and all the people who they deal with on the ground and in the
air).

No [function] is totally isolated from the others; if one element is inferior, it will have a
negative impact on all the others.

2.2. Focus of Learning

Since human errors are considered to contribute to more than 70 per cent of aviation
accidents, the major focus of learning in the aviation system is on improving
decision-making by pilots and other key stakeholders. In recent years, study of pilot
judgment and aeronautical decision-making (ADM) has been a mission of the Federal
Aviation Agency (FAA) and the National Aeronautics and Space Administration
(NASA).
To reduce errors of judgment and improve decision-making skills, a
decision-making model has been tailored for the system to fit different flying
conditions. It provides a logical decision making process, even when decisions must be
made under pressure. The DECIDE model, according to Krause (1996), stands for:
D Detect The pilot detects the fact that a change has occurred that requires
attention.
E Estimate The pilot estimates the significance of the change to the flight.
C Choose The pilot chooses a safe outcome for the flight.
I Identify The pilot identifies plausible actions to the change.
D Do The pilot acts on the best options.
E Evaluate The pilot evaluates the effect of the action on the change and on the
progress of the flight
This model is used both prospectively, to train personnel, and retrospectively, to
diagnose errors and, in some instances, to prepare case studies of known accidents.

2.3 Detecting and correcting errors

Although great effort is directed at raising the competency level of all those who work
within the aviation system, mistakes occur. In order for the aviation industry to learn
and improve, it must and does have a way of identifying errors. A black box is on
every commercial aircraft. It consists of flight data and cockpit voice recorders. Faith
(1997) wrote that black boxes are the best single source of information for
investigators. As a memory, they provide data on the long series of events that occur
during a flight. Crucially, black boxes are completely objective. Because they record
events as they occur, they are exempt from interference and influence. (As will be
TLO discussed later, this is an important requirement for any learning system, particularly
19,1 where organizational managements have opportunities to exercise defensive activities;
Argyris, 1990). Analysis of the data in black boxes enables investigators to compare
expected happenings with what actually happened, and to determine where the
difference between them has occurred.
Determining what caused deviations from expectations is the responsibility of the
80 National Transportation Safety Board (NTSB). Its main function is diagnosis and
prescription to investigate accidents, identify their causes, and recommend
improvements. In order to achieve a high standard of excellence, the NTSB is a
professional body with its own investigators and methodology. Faith (1997, pp. 24-5)
makes this point:
Air-accident investigators, or tin-kickers, are a very special breed. In one sense theyre
detectives operating in a very specialized field, but, at a senior level, they have to be capable
of co-coordinating, and thus of comprehending, a far wider range of professional skills than
their equivalents in the criminal field.
Despite its responsibilities, the NTSB has no regulatory or enforcement powers. Once
the cause(s) of an accident have been determined, the NTSBs recommendations for
action are sent to the Federal Aviation Administration (FAA), which sets and enforces
air safety standards. In addition, the FAA plays a major role in assuring system
efficiency, regulatory reform, sharing and analysis of safety information, surveillance,
inspection, and accident prevention.

2.4 System memory (knowledge repository)

In order to provide high quality input to relevant decision-makers, the FAA has created
the Aviation Safety Reporting System (ASRS). It collects voluntarily submitted
aviation safety incident reports in order to reduce the likelihood of aviation accidents.
ASRS captures information about such things as emergency landings,
mechanical/maintenance problems, security, health related fatalities, injuries and
illnesses, operational problems, and passenger disturbances. This information is used
to identify and remedy deficiencies and discrepancies in the National Aviation System
(NAS). Lessons from mistakes are documented and organized for easy access and made
available to those who need and are authorized to receive it. In this setting, there is
constant support for policy formulation and system improvement. Also, in many
instances, expertise is leveraged across the system.

2.5 Accidents and lessons learned

It is important to understand how these different components of the commercial
aviation system function and interact with one another and with the rest of the
environment Such interactions are best illustrated by a couple of examples of how
major accidents produce lessons learned. The examples are cited from the transcript
of NBC News with Tom Brokaw (2000).
Accident #1: On a clear night on September 8, 1994, a USAir Boeing 737 fell from the sky nose
first and slammed into a wooded area near a small shopping center in Hopewell Township,
PA. The aircraft shattered on impact and all 137 people aboard Flight 427 were killed.

Lesson Learned: Both this and a 1991 Colorado Springs plane crash give the NTSB and
Boeing the opportunity to focus on the 737s rudder control system. NTSB investigators
 discovered that the Boeing 737s rudders can jam on rare occasions, and when pilots try to Sustainability
correct the problem, it could steer the plane in the opposite direction. In August 1996, the
FAA prepared to make recommendations for changes in the flight control systems of the and lessons
Boeing 737. In 1997, the FAA indicated that it would issue four Airworthiness Directives learned
requiring all 737 operators to implement improvements, proposed by Boeing, to the rudder
system within a two-year period.
On April 16, 2000, A US Federal Aviation Administration scientific panel recommended
long-term design changes to the rudder of the Boeing 737. 81
Accident #2: At twilight on Feb. 1, 1991, 12 people in a Skywest Fairchild Metroliner
commuter plane were waiting to take-off at a runway intersection when a USAir Boeing 737
landed on the same runway. All 12 people on the commuter plane and 22 people on the 737
were killed. One air traffic controller sent the commuter plane to the runway to await take-off,
and later told the Boeing 737 to land on the same runway.

Lesson Learned: In response to the Los Angeles collision, the FAA issued a rule limiting
takeoffs from the middle of long runways. Specifically, the rule prohibits planes from entering
runways at taxiway intersections and holding there for further clearance. The rule is in effect
from sundown to sunrise, and around the clock at intersections that are not visible from
control tower windows.
In both of these cases, the NTSB was called on to investigate and find out what went
wrong, what lessons could be learned from the crash, and what could be done to avoid
similar accidents. Its initial step in both cases was to find the black boxes for analysis.
In the first case, examination of the black boxes exonerated the flight crew. For a while,
the focus of the study was on the flight environment (being too close to another plane).
Finally, the result of the most extensive study in the history of aviation accidents
culminated in recommended redesign the rudder mechanism in 737s. In the second
accident, the investigation also found no wrongdoing by the pilots. In fact, they had
complied with the instructions given to them by the air traffic controller at Los Angeles
airport without being aware that another flight had been cleared to land on the same
runway. The investigation of accident concluded with a recommended change in
FAAs policy and rule for commuter aircraft take-offs. The FAA throughout the USA
is currently enforcing the new procedure.
Once an investigation is complete and recommendations for change are made, all
the reports are saved in the NTSB Aviation Accident/Incident database. This and other
electronic repositories (e.g. Air Crash Rescue News and Aviation Safety Institute
database) form a distributed memory for the whole aviation system. The lessons
learned from past airline accidents are applied to prevent the future accidents.
Through the interaction of the functional components described above, the
commercial aviation industry has created a learning and adaptation support system,
which has significantly and effectively increased air travel safety.
The characteristics of such a system can be employed by any organization to
improve its performance. This applies equally well to organizations involved in the
TBL sustainability journey.

3. Organizational learning and adaptation (L&A) model

In 1997, while flying in a corporate jet, an executive of a Fortune 25 company was
reading a corporate report and noticed a very poor performance compared to
expectations (sales volumes, penetrations, unit profitability, unit cost) for two of the
TLO companys products. He wrote the following memo: How come these products are
19,1 performing so poorly vs. our expectations when the products were conceived? What
went wrong?. This questioning had coincided with the companys decision to develop
a system to facilitate organizational learning and adaptation based on the conceptual
framework developed by Russell L. Ackoff (1999). In this approach, the focus of
learning is on improvement of decision-making. The model is based on experiential
82 learning and assumes that learning occurs as a result of detection and correction of
errors.
The following steps represent the logical flow of experiential learning in the L&A
model:
.
Decide Choose a course of action and make a record of the decision (as
described below).
.
Act Take action or instruct others to do so.
.
Monitor Track the implementation, expected outcomes, and the validity of the
assumptions on which the expectations are based.
.
Detect Identify any significant differences between the performance observed
and expected outcomes and assumptions.
.
Diagnose Determine the causes of mistaken expectations and assumptions.
.
Prescribe Initiate changes in the system or its environment based on the
diagnoses and prepare a decision record on such action.
.
Evaluate Assess the impact of the prescribed changes.
.
Retain Collect lessons and make them easily accessible to all those authorized
to receive it.

For the company mentioned above, the L&A model was utilized to reconstruct the
decisions that led to creating the under-performing products. Using a decision record
template as a starting place, the decision makers, the strategic context for the decisions,
arguments pro and con, expected outcomes, assumptions on which the expected
outcomes were based, who were responsible for the implementation, key information
used, and the decision making process employed were identified and recorded. This
process was similar to the retrieval of data from black boxes in the commercial aviation
system described above.
For every decision, there are two sets of variables that should be made explicit and
monitored. First, in the case described above, expected outcome variables such as
design cost, capital investment, volume, market share, profit, quality, warranty, and so
on were identified and tracked. Second, assumption variables on which the
expectations were based were identified through the study of the program
development charters and business plans as well as interviewing the decision
makers. These included variables such as market segment growth, product life cycle,
program potential, pricing, customer preferences were identified and tracked. By
retrospectively collecting this data and plotting behavior over time charts, it became
apparent that the product programs were off course right from the time of launch.
Next, the challenge for the investigative team was to understand why this was the
case and why the attempts to correct these errors did not bear results for the product
management teams. The first significant finding was that the assumptions were never
made explicit, hence not monitored by the product managers in the early stages of Sustainability
development. If these assumptions had been identified and tracked, changes that were and lessons
taking place in the market segment impacting segment growth potential negatively
would have been detected and served as an early warning of poor product learned
performance. If these errors had been recognized at the early stages of product
development, particularly, before the launch, it would have led the management team
to reframe its expectations and perhaps change the outcomes. 83
It was important to demonstrate how the different variables were interacting to
create a system of problems for the product programs. By creating an influence
diagram, it became apparent that isolating problem areas and applying local remedies
(e.g. increasing advertising budget) did not help with the overall performances of the
programs. As a result of these findings, the investigative team recommended the total
redesign of these programs and change in the companys prevailing product
development paradigm (e.g. change in long development cycle times).
Today, the company involved uses an organizational system that is based on the
L&A model to improve strategic decisions by accelerating its ability to learn and
adapt. An organizational unit has been created to help with training and incorporation
of learning functions into the so-called common processes (e.g. product development
process). A standard format for capturing decisions in real time and committing
them to the organizations memory has been developed. Assistance with tracking
and comparison of the relevant expected outcomes and associated assumption
variables are provided in order to determine whether there are any significant
deviations. After diagnosis of the cause(s) of errors, assistance in prescribing corrective
actions is made (cf. NTSB).
There is an additional function in the L&A model that provides the decision makers
with the ability to anticipate threats and opportunities. This function performs
scanning and surveillance of the internal and external environments for significant
trends or changes. Statistical procedures are utilized to identify such trends or changes
in critical indicators before organizational performance is affected.
Finally, the decision-support function supplies decision makers with data;
information, knowledge and understanding derived either from inquiry or from
lessons previously learned. This function provides means by which learning from the
past is brought to bear on present strategic decisions.

4. Conclusion
Todays environments in general are characterized by uncertainty and increased
complexity, and decision making is a risky proposition. Increasingly decision makers
act on information which is at best sketchy and they are required to make assumptions
that necessarily are not tested. This situation is drastically exacerbated when an
organization undertakes the TBL sustainability journey. Nevertheless, decisions have
to be made and actions have to be taken. In the aviation industry, these decisions are
tracked and planes checked for being on course, errors diagnosed, and corrective
actions taken. This paper has demonstrated that there is so much that could be learned
from the aviation industry about organizational learning practice that could be applied
to management for sustainability.
The ability to gain understanding from experience requires the willingness to
examine both successes and, particularly, failures. Unlike the aviation industry, many
TLO organizational systems conceal mistakes and thereby reduce, if not preclude,
19,1 experiential learning. Unable to learn from their mistakes, they may fail to adapt to
customer needs and to improve their processes to meet increasing competition. This
defensive behavior is not new, but is pervasive and largely undiscussable (Argyris,
1990, 1993; Smith and Saint-Onge, 1996). Ironically, in this regard, the aviation
industry has been successful in increasing safety, but it has failed to utilize the
84 teachings from dealing with complex socio-technical systems and apply it to the
business of aviation. Witness the demise of airline companies such as Pan Am, TWA,
Eastern, Braniff and Peoples Express.
Like pilots on the flight deck, executives and managers are continuously making
decisions. But unlike the pilots, they are rarely supported by systems that help them to
navigate the permanent white water in todays TBL environments. There are
profound lessons here for the governance and C-suite levels of all organizations as TBL
sustainability gains ground.
Of great importance is the ability to examine the cause(s) of errors and to correct
them. In this regard, there are a number of critical attributes of the NTSB that are
worth noting. The NTSB for all practical purposes is an independent organization.
Moreover, it is a knowledge-based organization that derives its power from its
reputation for impartiality and thoroughness. Because of its standing and despite
having no regulatory or enforcement powers, more than 80 percent of its
recommendations are adopted. This is in stark contrast with the detection and
correction work that goes on in the corporate world under the banner of lessons
learned. Unfortunately, the scientific rigor that is required for creating high quality
learning is usually absent in corporate diagnosis processes.
In the Ackoff (1999) framework, once the recommendations for change have been
made and implemented, for further validation and confirmation, the changes
themselves are tracked. This enables what learning theorists call learning to learn.
This accelerates and improves the learning process itself.
Although the authors have focused here on elements that are necessary to create a
learning and adaptive system, they are mindful of the roles culture, technology,
structure, communication and environment play in high reliability systems that are
relevant to corporations (Smith and Sharicz, 2011). It is not beyond most organizations
involved in the TBL sustainability journey to adopt a system similar to that described
in this paper that would address single and double loop learning (Argyris and Schon,
1978). Given the ready availability of web- and mobile-based technologies in
organizations today, the provision of readily accessible black boxes and dashboards
also seems timely and practical. Unfortunately, managerial willingness to adopt such
organizational learning approaches is still suspect.

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About the authors

Dr John Pourdehnad is Affiliated Faculty, Organizational Dynamics at the University of
Pennsylvania, USA. He is also Associate Director, Ackoff Collaboratory for Advancement of
Systems Approaches, and Adjunct Professor, Systems Engineering, in the School of Engineering
and Applied Science, University of Pennsylvania, USA. Dr Pourdehnad is engaged in the field of
organizational management, using systems thinking as a worldview and communicating its
implications for management. As a scholar-practitioner he has been involved with numerous
projects helping management with the resolution of complex problems. He has taught at
undergraduate and graduate levels, worked as an educator/consultant with for-profit and
TLO not-for-profit organizations and government agencies, and has also been a co-principal
investigator in a number of research programs. He is a member of the Academy of Management
19,1 and of the Editorial Board of Systems Research and Behavioral Science. John Pourdehnad is the
corresponding author and can be contacted at: jp2consult@aom.com
Peter A.C. Smith is President, The Leadership Alliance, Inc., a wholly complex adaptive
systems based consortium of global associates. Peter maintains a worldwide consulting practice
focused on assisting leading public and private sector organizations progress their TBL
86 sustainability journeys based on his proven expertise in OL and the development of the
necessary systemic organizational and personal capabilities in traditional business
environments as well as in currently emerging networked contexts. He is Consulting Editor,
The Learning Organization; Publisher, Journal of Knowledge Management Practice; and
Assistant Editor, International Journal of Sociotechnology & Knowledge Development. Peter has
published widely in academic journals and books, and is in demand internationally as a speaker,
workshop leader and conference chair.

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