Safety Leadership Charter, Guiding Principle 5: “Create an atmosphere of trust, where employees are encouraged and confident to report safety-related information”.
Cathay’s approach to safety management has evolved beyond traditional notions of safety, which are solely measured by the absence of undesired events. While ensuring risk management minimises the likelihood of incidents and accidents, the airline also sees safety as the capacity to adapt in the face of unforeseen challenges. This shift, central to the Safety-II philosophy, acknowledges the complexity of modern aviation systems and the inherent variability and surprises in everyday operations. Instead of just addressing what goes wrong, Cathay’s OLR is a key tool in understanding and enhancing how things go right. By systematically studying how staff successfully manage normal and non-normal occurrences, the airline bolsters its adaptive capacity.
This proactive perspective recognises that the airline operates in a dynamic environment where pre-defined procedures may not always align with real-world situations. Through the OLR, the airline seeks to identify how frontline staff—such as pilots, cabin crew, engineers, and ground crew—handle variability in the system, ensuring safety through flexible and creative problem-solving. Adaptive capacity, therefore, is the organisation’s ability to anticipate, monitor, respond, and learn from these situations, maintaining high safety standards even under challenging conditions.
The OLR was fully integrated into Cathay's Safety Management System (SMS), with the results of OLR sessions informing both short-term operational adjustments and long-term strategic safety initiatives.
As part of this process, lessons learned from OLR's were used to refine training programs, update standard operating procedures, and enhance communication between operational teams and management. This systematic integration ensured that the insights gathered from the OLR process were translated into concrete actions that continuously improved operational safety, contributing to Cathay's ability to maintain the highest standards of operational excellence.
Through this comprehensive implementation, Cathay was able to not only address immediate safety concerns but also strengthen its overall resilience by promoting a culture of continuous learning and adaptation.
One of the core benefits of the OLR is its ability to tap into the tacit knowledge held by frontline workers, which is often overlooked by traditional safety audits and investigations. This experiential knowledge, acquired through direct engagement with operational challenges, provides critical insights into how staff deal with complexity and uncertainty in real time. By systematically collecting this tacit knowledge, the OLR helps organisations bridge the gap between Work as Imagined (WAI)—the idealised version of how work should be done according to procedures—and Work as Done (WAD)—the real-world practices that ensure safety and efficiency. This process enriches the organisation's understanding of operational variability and highlights potential areas for improvement that would otherwise remain hidden.
From a safety science perspective, the OLR also plays a vital role in fostering a culture of psychological safety and restorative just culture. In high-reliability organisations like aviation, it is essential that employees feel safe to report errors and discuss operational challenges without fear of retribution.
The OLR process encourages open and honest dialogue by creating an environment where workers can reflect on their experiences, both positive and negative, and contribute to organisational learning. This not only helps in uncovering latent risks but also supports employee well-being by recognising their contributions to maintaining safe operations. In doing so, the OLR strengthens both the safety culture and the resilience of the organisation.
The successful implementation of the Operational Learning Review (OLR) at Cathay required a phased approach, starting with small steps that gradually built understanding and acceptance across the organisation.
The complexity of shifting from traditional safety methods to a more dynamic, learning-focused approach meant that a large-scale, immediate rollout would not have been feasible. Instead, Cathay took deliberate, incremental steps to ensure that the OLR process was understood and valued by all stakeholders. This began with pilot programs, where small groups of frontline staff, safety professionals, and operational managers were introduced to the core principles of the OLR, such as focusing on Work as Done (WAD) and capturing tacit knowledge. Over time, these initial efforts helped build the foundation for wider organisational change by demonstrating the practical benefits of the OLR in identifying and managing operational variability.
To support the broader implementation of the OLR, continuous education and reflection were critical. The Head of Group Human Factors invested in creating a range of training programs and courses specifically designed to educate frontline business units on the theory and application of the OLR method.
These programs were essential for developing a deep understanding of the OLR’s underlying principles, such as Safety-II, resilience, and adaptive capacity. The training covered not only the theoretical foundations but also practical guidance on how to extract maximum benefit from the OLR process. Workshops, simulations, and scenario-based training helped employees apply the OLR method to real-world situations, fostering a culture of learning and adaptation. The programs also emphasised the importance of reflection, encouraging staff to continuously evaluate their experiences and share insights with the broader organisation, thus contributing to a sustained cycle of improvement.
A key challenge of the training was developing the capacity of frontline business units to take ownership of the OLR process and actively participate in learning reviews. Cathay recognised that for the OLR to be effective, it needed to be embraced at all levels of the organisation, particularly by those directly involved in day-to-day operations. Specialised training sessions were designed to equip frontline teams with the tools and techniques to conduct OLRs autonomously, ensuring that the method was not seen as top-down but as an integrated part of operational practice.
Through these training programs, frontline staff learned how to collect and analyse data, engage in reflective discussions, and identify operational risks and opportunities for improvement. By empowering employees to apply the OLR method themselves, Cathay was able to extract maximum benefit from the process, embedding a culture of continuous learning and improvement across the organisation.
