Pre-Accident Investigations: Better Questions - An Applied Approach to Operational Learning, 1st Edition (Paperback) book cover

Pre-Accident Investigations

Better Questions - An Applied Approach to Operational Learning, 1st Edition

By Todd Conklin

CRC Press

138 pages | 9 B/W Illus.

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Paperback: 9781472486134
pub: 2016-05-27
eBook (VitalSource) : 9781315382302
pub: 2017-08-10
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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.


"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

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

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.

Subject Categories

BISAC Subject Codes/Headings:
TECHNOLOGY & ENGINEERING / Industrial Engineering
TECHNOLOGY & ENGINEERING / Industrial Health & Safety