Pre-Accident Investigations


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Better Questions A new view for safety is appearing everywhere This book is not about traditional safety... This book is about wisdom I Hate, "You Can't Fix Stupid!" People do not just become stupid To Ask Better Questions, First Understand and Stop Blame Access Knowledge from the Field and the Floor The scene The problem Blaming the driver is not a long-term solution The learning Not Knowing Is Powerful Safety is about learning Learning is a product of feedback Outcomes matter and learning matters Wise managers make better decisions See hazard identification as an outcome There Is Good News Why Learning Has Not Been Our First, Best Tool Let me make you breakfast: An illustrated discussion Not every event needs fixing A Learning Team Case Study Bob Edwards Free Willie: A case study for learning teams Why We Do Not Learn? Workers must be involved in problem identification Learn and improve Workers are fundamental Quick fix versus fix quickly! By giving up control, you gain operational intelligence Micro-experimentation Confidence is important Access reality when learning Learning should be simple so that learning outcomes are not simplified Learning happens on a diffusion cycle Fork truck versus pedestrian Discipline and learning Discipline is never an appropriate response to an accident The test for the proper use of discipline as a safety management tool Learning Teams What is a Learning Team? A Phased Approach to Learning Teams When to Learn? Phase one: Determine the need for a learning team Determine when to learn Questions to start your thinking about the learning process Do not start with problems that are too big or complex for the group Safety only? The team learns about the event, together Setting the stage for learning Who should learn for your organization? Does the team need a leader and/or coach? Does phase one matter? Summary of phase one Phase two: The first meeting-Discovery Stay in problem-solving mode Start a loose representation of the event or of the work in question So, what do we do if we cannot use a timeline? Identify conditions: Not choices List the conditions present in the event context Everyone has a perspective Phase two summary Let It Marinate: Build in Time to Think Phase three: Soak time! Phase three summary Phase four: The second learning team session Review, recap, and capture additional information Phase four summary Change Happens! Phase five: Define old and implement new defenses Micro-experiment your defenses, safeguards, and capacities Phase five summary Phase six: Track actions and criteria for closure Learning happens in many ways The power of small experimentation Success has many faces Tracking actions Phase six summary Shout from the Rooftop Phase seven: Communicate to other applicable areas Constantly search for "extent of conditions" Phase seven summary A Learning Team Case Study Bob Edwards Who buried Bill? Conclusion: This Book Ends and Your Work Begins Learning and improving The old is new again Why learning teams? How we ask questions changes how workers answer questions

About the Author

Todd Conklin retired as a senior advisor at Los Alamos National Laboratory, New Mexico, one of the world's foremost research and development laboratories, in the human performance and safety integration program. Dr. Conklin had worked on the program at Los Alamos National Laboratory for the past dozen years of his 25-year career. Conklin holds a PhD in organizational behavior and communication from the University of New Mexico. He speaks all over the world to executives, groups, and work teams who are interested in better understanding the relationships between the workers in the field and the organization's systems, processes, and programs.


"In his forward to the book, Professor Sidney Dekker says that questions such as "What rule was broken?" or "What should the consequences be?" are no longer good questions because they are short-sighted and elicit short-sighted answers. Ask better questions and you get the kind of answers that will actually help show the way forward. In this he echoes the aims of this thoroughly entertaining and thought provoking book." -The RoSPA OS&H Journal, October 2016 Issue

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