Pattern 09 · After and over time
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.
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
At 02: The ASRS is voluntary, confidential and non-punitive. NASA and the FAA set it up in 1975, with NASA holding the reports rather than the authority that enforces. Reporting has to cost less than staying quiet.
At 05: The ASRS feeds reports back out as safety alerts and CALLBACK, published monthly since 1979. A loop whose far end nobody can see stops being used.
Without / with the pattern
Anti-pattern: Reported and Forgotten
Crew learns something, then It goes in a log, then Next crew starts blind
Reported and Forgotten: the knowledge stops at the record. The crew on the flight before JT610 met the same nose-down trim, cut out the stabilizer trim and landed — but that action was not entered in the maintenance log, and the next crew took off without it.
With the pattern
Crew reports, then It reaches the engineers, then The machine or procedure changes
The report travels, something changes because of it, and the people who file reports can see that it did.
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.
Sources
What stands out about both accidents is that the knowledge already existed. The crew on the flight before JT610 met the same nose-down trim, cut out the stabilizer trim and landed; what did not survive was the record of what they had done, so the next crew met it cold.3 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.2 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.2
So 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.5 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.