John is an inspiring leader among engineers, but you don’t need to be technical to benefit from his message. Too often in government, we’re told to minimize risk and avoid mistakes at all costs. The reality is that mistakes and accidents happen when working with complex systems; how we respond to them makes all the difference in whether learning from them will happen or not. Systems and the cultures responsible for their operation can become more brittle and locked down, or we can learn from mistakes and become more resilient. The latter path starts with blameless post-incident reviews, part of management principles known as forward-looking accountability and just culture, which come from research in domains like aviation, medicine, and manufacturing. Evolving how we learn from incidents in these ways is critical to turning accidents into real investments in the future.
“blameless” post-incident reviews
learning by supporting
Adaptive Capacity Labs, LLC
How does our software work, really?
How does our software break, really?
What do we do to keep it all working?
“You should check this out!
This bit here doesn’t work the way you think it
• Teams of experts coping with complexity
• Under competitive/political/production
• High tempo, high consequence scenarios
• Elements of uncertainty and/or ambiguity
Air Traffic Control
Power Grid & Distribution
Safety comes from
people (not tech)
their work to the
situations they find
the “messy” details
what actions they took at the time
what effects they observed
what expectations they had
what assumptions they made
their understanding of the timeline of events as they occurred
the “messy” details
So we shouldn’t punish people for making mistakes?
How do you get “accountability”?
This could never
work in government.
”If people are punished for being honest about what
transpired, employees will soon learn that the
personal costs to speaking up far outweigh the
personal benefits. Improving the safety of a system
is rooted in information.
Anything that makes information more available is
desirable and anything that blocks information should
It is for this reason that the Learning Review seeks to
identify influences and never blame.”
United States Forest Service Learning Review Guide
4. USE, SHARING, AND RELEASE OF SAFETY INFORMATION
a. Privileged safety information shall be used for safety purposes only; specifically, preventing
mishaps and reducing injury and property damage resulting from mishaps.
b. Privileged safety information shall not be:
1) Used, shared, or released except as provided in this Instruction.
2) Used to support disciplinary or adverse administrative action, to determine the
misconduct or line-of-duty status of any personnel, or as evidence before any
3) Used to determine liability in administrative claims or litigation, whether for or against
4) Released in response to requests for information pursuant to section 552 of title 5,
U.S.C. (also known and hereinafter referred to as “FOIA”) (Reference (ab)). Requests
are submitted in accordance with Reference (w) or in response to discovery requests,
subpoenas, court orders, or other legal process except as provided in section 10 of this
5) Privileged safety information may only be released as provided elsewhere in this
Instruction or upon specific authorization by the Secretary of Defense.
Want to know more about how to do this?
Come to the breakout session on this topic later today.