1st Edition

Pre-Accident Investigations
Better Questions - An Applied Approach to Operational Learning

ISBN 9781472486134
Published June 7, 2016 by CRC Press
160 Pages 9 B/W Illustrations

USD $54.95

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Book Description

Pre-Accident Investigations: Better Questions - An Applied Approach to Operational Learning challenges safety and reliability professionals to get better answers by asking better questions. A provocative examination of human performance and safety management, the book delivers a thought-provoking discourse about how we work, and defines a new approach to operational learning.

This is not a book about traditional safety. This is a book about creating "real" safety in your organization. In order to predict incidents before they happen, an organization should first understand how their processes can result in failure. Instead of managing the outcomes, they must learn to manage and understand the processes used to create them.

Ideal for use in safety, human performance, psychology, cognitive and decision making, systems engineering, and risk assessment areas, this book equips the safety professional with the tools, steps, and models of success needed to create long-term value and change from safety programs.


Table of Contents

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
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

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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