Thread by @lhochstein

Liked this quote from Todd Conklin's "Pre-Accident Investigations" book:

"Failure happens because the worker believes that what is about to happen to them is simply not possible."

"It worked last time. It worked the last 10,000 times. Normally, it always work OK. Why would it not work the next time?"

"Most of the stories I tell in my work are stories about the way the organization failed the worker, and almost never about how the worker failed the organization."

"Every failure that takes place happens because some defense either did not work or was not present in the work environment."

"The consequence of a failure does not determine the importance of the failure."

"'What is the difference between a big event and a small event?' The answer, and I think I have heard them all, really should always be, 'nothing.' All events allow us the opportunity to learn."

"Small events, those events with small consequences, are often much richer in context and story than what our organizations define as large events."

Great story about last minute equipment officer crew change on the Titanic. Old officer accidentally took key to the equipment storage locker, which contained the binoculars. New equipment officer couldn't find replacement key, led to Titanic lookouts not having binoculars.

"Errors, near misses, good catches, close calls—any of these factors could indicate there is a problem, without the actual consequences of the failure. Safety professionals look on indicators of this type as 'gifts.'"

"Many of our systems are set up to be effective accounting systems, and not good work management systems. These systems are rife with potential failures." Not my domain, but I can't help but think of health IT here.

"Look for conditions that lead to failure, not trends or numeric patterns, and when you find these conditions, learn from them."

"Workers don't cause failure; what workers do is trigger a whole lot of weaknesses that exist in environments, processes, systems, job sites, and in the work or organization itself. These weaknesses are not new or unusual. These weaknesses are always present in your organization"

"Culturally, we have become trapped by the idea that everything must have a cause."

"Not knowing what caused an accident is downright scary."

"One of the strongest drivers to ... identify a root cause is the fact that it is much easier and cheaper to ... fix *one* cause than it is to look at an entire set of processes and relationships that exist throughout an entire organization."

"In many ways we construct cause in order to make our need for the creation of improvement actions quick, simple, and sustainable."

"Error is not a cause, nor is it an effect. Error is simply error—an unintentional deviation from an expected behavior or outcome."

"As workers adapt and improvise solutions to 'discovered work,' new dangers are also discovered. In the environment of discovery, our workers are now dealing with hazards that we have not planned for, mitigated for, protected for."

"The more you know about how work happens, the better prepared you will be to help workers create safety in practice."

"The idea that by identifying the things that the worker should have done in order to avoid this accident the organization would be able to either change history or prevent the next event is foolish, but extremely attractive when answering the question, 'why did this happen?'"

"The biggest enemy of safety is dogma – the belief that we already know the answers to the questions our organizations are forced to ask."

"Everything you do to increase your organization's ability to learn makes your organization safer."

"The most important and in many ways the easiest change you can make is to change your management team's reaction to failure."

"You can't measure things that don't happen, but you can talk about changes in attitudes, communication, and early problem identification, and excellent catches that are happening in the field."

"Change happens through dialogue ... Move your managers by talking to them about what is admirable in the way they manage safety, and where there is potential to develop a new way to see work and workers."

"Remember: failures tend to be unexpected combinations of normal performance variability."

"It is also worth reminding each other that the parts of an event are not as interesting as the relationship between those parts."

"The space between the organization's idea of work and the workers' idea of work is where learning about safety happens."

"The most significant safety management tip in the world is pretty straightforward: never place a worker only one defense away from a failure."

"The workers can tell you where the process is especially strong, and where the process depends more on the worker to create safety than on the processes and systems."

"We are emotionally wired to blame ourselves for mistakes that, in retrospect, seem stupid."

"You will be surprised at the change in your organization the first time one of your managers asks in an incident review, 'how did we set up a worker for this failure?' as opposed to the normal question, 'what were you thinking when you stepped off that scaffolding?'"

"Think in small steps. Think one person at a time. It does not sound efficient, but it is the only way to make change stick."

"Simply by seeking to understand the story and context that surrounds a failure, you will see safety get better."

"The ability to detect and correct all the conditions that normally exist as precursors to failure is not easy, and, most importantly, not accidental."

That's it! I highly recommend the book: amazon.com/Pre-Accident-I…

Bonus final tweet: Conklin has a podcast as well, with the same name as the book. Check it out: preaccidentpodcast.podbean.com