Bob said the craziest thing last night at Meow Wolf, which I was actually really surprised you kind of liked Meow Wolf.

I didn't put that in your category.

We've got a hippie daughter.

I know, I know.

Bob was kind of in a contemplative mode after he got out of there.

I know he's probably all freaked out by all the many stimuli.

And he said, have you been thinking about your last day on Earth?

And I said, well, not that much.

Why do you ask?

He says, I've been thinking about a lot.

And I said, what do you think it's going to be like?

And he said, it's going to be like every other day of my life, just shorter.

Thanks, everyone.

This was fun.

Music.

Hey, everybody.

Welcome to the Pre-Accident Investigation Podcast.

I'm Todd Conklin.

How are you?

So today is a big day.

Well, it's kind of like any other day, really.

But I think it's going to be a big day because, well, it's a big podcast.

First of all, it's 45 minutes long.

Sorry.

But today's the day where we do the open and not open and closed.

What's wrong with me?

The open question and answers at the end of the conference we had this couple weeks ago in Santa Fe.

And I always think this is interesting because it gives you guys, if you didn't get to go to the conference, first of all, we missed you.

It was really fun.

But if you didn't get to go, it gives you kind of a handle on what the topics were, what people were interested in.

And I'm actually really encouraged by these questions.

There's lots of really interesting questions that I would say are kind of the next level up questions.

They're not the sort of how do I get my boss to listen, although that's an important question.

But these are, you know, okay, we're learning.

We've got some good ideas for corrective actions, but they're not defusing very well.

That's a pretty good question.

And you'll hear that.

I mean, that's a big part of the conversation and a big part of what the podcast is all about.

The conference was super fun.

We had a whole lot of people.

Everybody had a great time.

No big dramas.

Well, that's good.

We did drag everyone to a place called Meow Wolf, which I don't know how to describe except kind of look it up if you get a chance to Google it.

It's kind of this sort of hippie-centric, no, no, let's call it hippie-adjacent art installation that's large enough you can walk through.

And it's pretty interesting.

It was a fun thing to do.

And people, for the most part, had a great time.

So that worked beautifully.

It was great.

And then we had a great crowd of people and really good Mark Yeston presented and Martha Acosta, Jennifer Long, Andrea Baker.

Bob Edwards, it was a really good crowd.

And we talked about, we covered lots of ground.

So it was fun.

We missed you.

You were missed.

But you can feel included because you can listen to the questions and anything else.

I mean, you know, everything's wide open and it's all yours.

How are you doing?

It has been crazy.

It's hard to even understand where to talk about stuff.

Because it's just, everything's crazy and super dramatic and bizarre and weird.

Who knows?

The only good news for me is that I'm going to go to the Bluegrass Festival in Winfield, Kansas.

So I probably have some, I'm thinking I'm going to come back with some, you know, hot new bands that you should be listening to.

I always try to do that.

Oh, you know, that's good.

That's where I found Seth James.

And if you're not listening to Seth James, you should be, right?

Years ago, I told you early on about Billy Strings.

Now you're in.

So let's enjoy the podcast because it is pretty long, but I think you'll find it really interesting.

So basically, the presenters and some guests set up in the front of the room, and then people just ask questions.

And we used one of those things where you could type them, and it immediately goes to the projection screen.

But we also passed around a microphone.

You'll hear both.

And you'll kind of figure out who the folks are.

There's a pretty interesting crowd.

James Frederick is there.

Charles Major is there.

Britton Sutton's there.

Andy, Bob, myself, Martha, Jenny.

There's a good crowd.

You'll kind of know who people are, but I think you'll find this pretty interesting.

So without any further ado, here is the Open Questions 2025.

So I'm curious about other things that we might be able to measure.

We're all under immense pressure or pressure to measure things.

And we've talked a lot about capacity, and we've got some ideas around that.

And so I just wondered, with this group in front of us, if there are any ideas of value-added metrics that might benefit our organizations.

So before we start to answer, and I'm super curious what the answer is, I would add to your thought chain the difference between the word metric and the word monitor.

So, I think it's really significant to understand that when we talk about a metric in an engineering-centric organization, we're really talking about something we can measure.

And so we know if we can measure it, that it's already happened.

And so it's always going to be a historic referent of what has taken place.

Metrics are pretty important.

Who am I kidding?

They're super important, and we've made them more and more important in our organizations.

However, metrics have a very difficult time describing the present, and they suck at predicting the future.

Fair enough?

No arguments?

Enter the word monitor.

We really want to look at things we can monitor in real time and trend the ability to monitor.

And the example I would use, just because it's one that resonates with me, is the gas gauge in your vehicle.

So you don't really demand an accurate metric for how much fuel is in your vehicle, and yet you need to know how much fuel is in your vehicle.

And so you monitor your vehicle's fuel by looking at a gauge that is not terribly mathematic, but in fact, incredibly visual.

And so part of what I think we have to do with our organizations is help them understand the power of metrics for understanding what has happened and monitoring for understanding what is happening.

It's how we do predict meetings, right?

It's how we do predict meetings where we're monitoring for vibration and things like that, right?

So you start to see it getting worse and worse and worse.

It gives you an idea, hey, maybe we need to work on it.

So you can monitor.

Actually, a lot of things can be monitored.

A good example, one organization we've been working with, we've moved to more of what we call a narrative-based or evaluative-based metric.

And the example that they used was they were trying to move away from the traditional LTFR or TRIFAs.

Data so they inversed it and they called it human reliability rate which basically we're not harming people this amount of the time rather than the other way around and then the third thing they looked at the second thing they looked at was their um critical critical control verification rate.

And once again there was a number involved because it has to be a number but the evaluative component was more about which of the themes were repeating.

Because leaders had this feeling that everything has to be 100%.

Yet these guys were only ever getting to maybe 96, 97%.

And by the way, that's amazing.

To get to that number is truly amazing.

But they're really interested in what were the themes that kept repeating in that space?

Because that was more about the work and the design of work.

And then the third thing they were presenting to those leaders as a metric were the themes that were coming through from all the 40 conversations at the front line.

And not surprisingly, every month there might be 20 or 30 patterns or themes that were coming through.

So the leadership is seeing reliability of humans.

They're seeing the reliability of controls and huge adaption in the field and the work.

And that made them curious.

And the curiosity wasn't about how to reduce the adaption, but the curiosity was to understand how is the work creating that adaptive process that was going on?

How do we shift our organization's thinking?

And this is by someone who's not American because they use an S.

How do we shift this?

Todd.

How do we shift this organization's thinking from managing risk to maintaining control?

So the quick answer is leverage what your finance people do.

They, that's how they think of risk.

I mean, you're finance people, you have a whole group in your organization who doesn't see risk as a threat.

They see it as an opportunity, right?

So when Barry and Ben were talking about generating power and buying and selling power, risk to them is not a threat, it's an opportunity.

So they really understand the whole process capability, the capacity idea.

And so that's a pretty powerful thing.

But that shift's a big shift.

The exciting thing about it is that what it really does is give the leadership team something new to go out and look at.

And that's a really powerful thing because we tell them all the time, if you want different answers, you have to ask different questions.

And then they look at you and say, what questions do you want me to ask?

Which is really fair.

Part of what you do is you say the conversation changes when you don't go out and identify the sticky.

You go out and talk about the controls.

And what's interesting to us as leaders is not the presence of risk.

That's pretty normal.

The interesting thing to us as leaders is the absence of control.

We really want to know where our processes are out of control.

And so that becomes a really powerful new thing to look at.

And because it's new, it's pretty novel.

And what it does, it's a little bit self-fulfilling because when they go to the field and ask that question, They really do get different answers.

I mean, hugely different answers.

Charles, build on that because you've thought about this a long time.

Less than three seconds so far.

So the risk.

Yeah, so I really don't know what else to add to what Todd had to say is that change the way we look at risk as really important.

Really more of an opportunity for something to go well or something to go wrong.

And then for us to understand what can we proactively start doing, looking at different measures than we have in the past.

I think it's somehow connected to the last question in my mind, is that what could we start monitoring that gives us an idea better about what risks are currently out there that we could do something about?

I think this idea of opacity is really important as far as for leaders to be looking for places that things are opaque.

Okay, being from a business school, and many of you have looked at these things, but the balanced scorecard for strategy is something that every executive knows something about.

And one of the things that people miss in that balanced scorecard when they're trying to have measurements for all of these different areas, the financial ones are easy, is that they fall in love with a certain measurement.

And really the way that it was designed was to keep changing the things that you're measuring to monitor how you're going in there because it's so easy to create blind spots.

So part of your monitoring process should be, what are some of the things that we don't know that are opaque, that are, you know, that are ambiguous in the information?

Where are some of the information missing?

What are some of the unknowns that we might have?

And that is actually much better information than where have we succeeded and where have we failed, because the success and the failure have already given you information.

The thing that you should be afraid of are the unknown unknowns.

So again, related to that last question about what to look at in monitoring and measuring, I think there are a number of things in your safety and health management systems that you can look at much more efficiently to monitor how are we doing?

Are we getting better?

Are we seeing things happening in a positive direction?

Think about things like an occupational health.

Think about things like the whole HOP implementation and just try to look at those as part of that system.

There's a number of things on that.

I put together a little piece that was in one of the trade publications a couple of months ago about kind of eight habits of highly effective management systems.

And, you know, there's some interesting things to talk.

Further question about moving from looking at things through the lens of risk to control.

There's been a couple groups that I've gotten to speak with fairly recently where that was a really, really tough switch.

And in most things, the proof is in the pudding.

So a lot of the times when we think about control for a senior leader level, part of what they're thinking about in terms of control is whatever that they've historically labeled as critical rule or a lifesaving rule.

And so when we start talking about how important controls are, I would just ask them about the health of the control.

Hey, can you teach me about the health of your control?

Usually that would bring up quite a few questions of what we meant by health of the control.

And so I say, well, if you went out right now in the field, how many exceptions do you have to your life critical rules?

And the answer is usually none.

And I say, well, there's none on paper, but how many exceptions in real life do you have to your life critical rules?

Because if that's what we're saying our control is and we have exceptions to it, then the health of that control, it's probably not very strong or we need to do some change around it.

And then in a little bit of conversation, people in the room would be able to say, well, there probably are quite a few exceptions.

Actually, we know that there are exceptions.

And then the next question is, well, what are we doing about it?

And that's usually where people get stuck.

And that's a bit of the conversation of shifting the thought process from focus on risk to focus on control, because if you can pick something that people know that they're trying to use as control today and you can show quite quickly and clearly that, hey, it's probably the health of it isn't as strong as you think it is, maybe we should go learn about that and make that better as a place to start.

It gives people a tangible place to start thinking about control differently.

So that's just an example of how you might do it.

Andy just said and asked you guys, how many of you guys have a pretty solid control validation and verification process?

So one, thank God you raised your hand or had a bit of pretty quiet.

I'd be like, oh, I'll wait.

But I think this is so interesting because, so I come from a world where we would talk about this as really like, are your controls efficacious, right?

But I've been told I can't use the word efficacious.

So I'm supposed to replace it with, are your controls in place and functioning, which I would suggest is also efficacious, but we can talk about that.

I mean, the idea that people, that we don't validate controls is really an important thing for us to be thinking about as an organization, because that's really a monitoring.

I mean, Andy just said it.

That's a really important monitoring, and it's actually relatively easy to verify and validate in the field.

Verification and validation of controls is not an audit, it's not an inspection, but it is going out and testing the controls that are in place.

It's also an incredible opportunity to have this conversation that Annie's talking about.

And really, what I would suggest to you guys is that's an area of growth on your operations side that simply is not optional.

I can't think of a reason why you wouldn't do it.

You want to know if your controls are fine.

You want to test your controls.

And you want to test your controls before something happens.

So you need to know before that, before you fall off the clip with that rope catching.

Right.

Exactly.

And if you think about mountaineering, that's a great example.

The one I'm thinking about is Bob and I, and I think you were there, Andy, we were at a paper plant and the general manager of the paper plant said, we had a fire last week and he's really upset about it.

We evacuated the plant with no injuries in 15 minutes and the fire team responded and he said it like it's a bad thing, like look how much we suck.

And Bob said, I'm having a hard time making that a bad story.

That's the best verification and validation you could have of your emergency response system at this facility.

And that little comment that Bob made, do you remember this at all?

Yeah, yeah.

It was someplace in, I remember it was stinky.

Yeah, right, because of paper mill.

Yeah, there are.

But that little comment that Bob made changed the entire trip for us because it went from a we're one banana peel away from dead to when you test your system and it functions, you should be celebrating that and learning from it.

And that's where those drills and stuff come in, too, like Crowley out there.

And we got to spend some time with them.

And they were testing their emergency response by actually getting the light boats out and ready to go and all that stuff.

And one of them hung up and did not work well at all.

Nobody lost their crap about that at all.

They're like, glad we did the drill because now we know that thing can hang up and it was corroding.

We didn't know it.

And so some of this stuff is we don't know until it's too late and then it's not working.

That's not okay.

I test my fire extinguishers and check them on a regular basis because Caden uses them.

He catches stuff on fire and he knows how to put a fire on.

He's been able to do this since he was three.

I'm either raising a special forces ninja guy or a terrorist.

I believe the word is arsonist.

Yeah.

Well, he blew up my neighbor's mailbox.

Still fits in arson.

So Andy says this about controls.

I think it's really smart.

If we have controls in place that really try to control the human, what do humans tend to do when you try to control them?

Oh, man, it's like squeezing Play-Doh, right?

I mean, when you try to control me, you ask me, I'll go to the ends of the earth for you.

You tell me, I'll die first, right?

But when you put in place controls that help people be successful and save them, right?

Not if, but when something happens that actually keeps them from dying or having a really bad day, those are controls and some of those like auto braking you don't even know you have until it kicks in because you fail to stop i don't think we do enough of that in industry i think the automotive world's done some pretty good work in that space i think we need more auto braking things that'll kick in when me the human because i don't think humans are reliable i think we're adaptive and resilient i mean storm rolls through we get up clean stuff up get back on track adaptive we're always adapting we're not very reliable i mean i'm two sigma maybe on a good day And so the reality is humans are incredible, but we count on them to get it right all the time.

So controls need to help us.

And I love what Todd said about, let's go check them out.

Let's test them.

Let's see if they're actually going to hold up when things go bad.

So there's two questions I ask because I like to ask questions that are storytelling based.

And one question is, with this control, can you share a story with me when it supported work to go well?

And then can you share a story with me when the control hindered the work and you see a whole different picture because the function is one part of it.

The help or hinder component, which is standing on what you're saying, is equally as important.

But by starting with the help, it gives you much better context when you move to the hinder.

So from a psychosocial perspective, I know which is a bit of an unusual word to use here around psychosocial risk, if you start with how it supports you, you'll get better on the other side.

I just wanted to get us back to the kind of the questions.

I thought we were done.

Well, no, but I saw a few questions that seemed to kind of ask the same thing, which is when you have two companies that are working together and one is strong and heavy kind of in their hop journey and the other is not, how do you help one another?

How do you help kind of bring them along on the journey with you?

Or even maybe you're both on the same HOP journey, but you're in different spots.

How do you kind of bridge that gap?

There's been a few organizations that I think have done this pretty well.

I don't think ours was one of them because we weren't far enough along.

We don't exist anymore.

But, I mean, the first thing that they did was invite them to any training that they had, right?

So if you're working with someone and you realize that, hey, in order for us to be really successful, we're going to have to be on the same page, they intentionally invited them.

There was one organization that actually created training for all of the folks that worked with them.

I honestly think from the stories that they've said, it's just a lot of patience and the willingness to teach them as though they were part of their own organization.

But at the leadership level, the place where it seems to matter the most and where you can have a pretty, I would think, succinct conversation without having to go into the whole detail and philosophy is when you have one group of folks reporting to another.

So picture like a contractor, subcontractor situation and the folks that are subcontracting or the folks that are contracting the subcontractors, if they don't want the subcontractor to, for example, remove somebody from the job site because they're on this hop journey, we're like, hey, that's not the response that you have to have.

They had to be very explicit with what they wanted the contract team to do or the subcontract team to do when something went wrong, like very explicit.

And say that we know historically we've asked you to remove somebody from the job site when this happens.

We are asking you very specifically not to do that this time.

We're going to respond differently.

And they had to have that meeting up front in their contract piece of it.

When it's the opposite, it's really, really hard because obviously the dynamic is quite different.

And I can tell you the practical things of what people do.

I don't know a good solution to it, but I can tell you practically the stories that I've been told is when you really don't feel as though you have the authority to sort of push back on the response that somebody's had.

What they do is...

They remove the person, right, as requested, and then they go operationally learn themselves within their own space and time to make sure that the next time that they face this, they can set themselves up for success.

But they haven't pushed as hard back as they historically would maybe have wanted to because they didn't feel that the power dynamic was there, where they basically brought the person back into the fold of their organization when something went wrong, said, hey, we're going to operationally learn amongst ourselves.

We're going to share the information, but their response was very similar to how it was historically.

And Helen, that's a lot what I see sometimes the inverse.

But we hire contractors and something goes wrong, especially around lotto, and we'll get on a learning call and they'll talk about what happened.

And then we might ask about the worker and say, oh, don't worry, we got rid of the worker.

Now, what that actually means is that they're just removed from our site, right?

They say they fired them, but they really moved them somewhere else.

It's really not that draconian, but it's still sending the entire wrong message around learning.

So what happens is we get on a learning call with these events and if you're in our gate, you're our people, man.

We care about you.

We train you just like we would our people.

And we want to learn with you just like you're our people.

So when it comes to this learning call and they say, oh, don't worry, we fired or removed this guy.

Well, we can't direct their work, right?

There's legal reasons.

We say, hey, I know I can't tell you how to treat your workers and exactly what to do there.

But next time something like this happens, I would really love to hear and learn from the worker about the context and then see a plan that you have about why we're going to change the way we do the work so it doesn't happen a second time.

And Barry Boswell on this call says, why did you fire the guy?

They say, because I thought that's what you would want us to do.

Right.

Because that's the natural, normal response is people want to see strong action in this some way.

And we say we want to see strong learning.

In the beginning, when we're setting up an outage, so we go from like 300 people on site to 1,800 people or 2,000 people on site.

We get the leadership teams, all those guys together.

We tell them about our learning versus blame culture and that we want you to be part of that.

We cover some of the principles with those guys and we say we want to learn and hear from you.

And then we actively go out and we talk about these hot principles at breaks and those kind of things with them.

So they receive some training up front, but then we reinforce it all the way through the cycle because we know things will go wrong.

But the less we know, the more things will go wrong.

The only thing I would add to this equation is that I actually think this is a symptom.

I mean, it feels like a problem to us in this room because it is a problem, but it's actually a symptom of the relationship both informal and formal we have made with our contractors.

And I think we really have to think about that relationship changing.

So part of what I would suggest is that we probably should talk about how we're going to respond to an event as a drill before we actually respond to an event.

So one of my favorite stories, it's the rubber glove potato salad story, is in Calgary.

What's that fancy Fairmont?

That fancy, fancy place.

Is it the Fairmont?

I mean, it's swanky McPancy fancy.

I mean, shirts and shoes required kind of place, right?

So there was a big oil sands company that was about to flip a switch, and they were going to go from 300 employees to, like, seriously, 6,000 employees on a weekend.

And they'd prepared for it.

They had man camps, I'm sorry, people camps.

They had more toilets, bigger sewer ponds.

I mean, they were ready for this to happen.

But before it happened, the senior executive of the company that was about to grow brought in all his contract leadership, all the personnel representations, and they brought him to this fancy fairmont.

And it was pretty remarkable because the entire agenda for that meeting was one item.

We will have an accident.

Something will happen.

And when it does, how are we as a collective leadership team going to respond to it?

It was remarkable.

And what's interesting is they did have an accident.

Something happened, of course.

And because they'd done that rehearsal, they'd really played out the accountability that they had to each other as the company.

And they had the contract people and the lawyers in that room.

So that conversation is a really important conversation.

We're growing into a problem that we didn't know.

Well, I think we always knew we had this, but now it's becoming more profound.

We're going to have to really look at how we have those relationships with our contractors.

Because Charles is right.

If they're on your site, they're your people.

It's pretty painful when a contractor dies, just like it is when a worker dies.

And so that's a really important thing to think about.

Okay, you want to hear the rubber glove story?

So we're at this fancy fair.

I mean, this place is like, they got a guy that hands out the tea.

I mean, it's fancy.

And they bring this meal out for lunch, and I'm sitting next to the CEO guy because they made me.

That's not my style.

And they bring out this potato salad, and I love potato salad.

And I'm eating it, eating it, eating it, and there's something that just won't break down.

At first, you know, you kind of think it's celery because celery is a tricky vegetable, you know, stringy, and there's a lot going on.

And so I take my napkin real subtly because I'm sitting next to the CEO guy, and it's pretty snooty.

And I just go like this when no one's looking, and it's a rubber glove.

Now, I don't know what your recipe for potato salad is, but mine doesn't have a rubber glove in it.

And so when the waiter came by, because there's a million waiters at this place, I just handed him my napkin, and I said, tell the chef this ingredient is not in my recipe.

And he took the napkin and walked away because that's the kind of place they are.

I mean, they're like, yes, sir.

And pretty soon i could see heads looking around the corner but i don't know why you guys had that been a hair or a band-aid i think i would have probably just puked right there but i i don't know why the rubber glove it didn't it i don't know it just didn't seem that bad to me i was the weird yeah i mean it's a kind of and so i didn't think a thing about it and the meeting went on.

They did come out later in the afternoon and they have their own kind of tea they serve.

And they said, we'd like to give you a box of this tea to say thank you.

And I said, well, okay.

I mean, I just wasn't a big deal to me.

Then we had the nightly dinner.

Have you ever been to one of these where all the senior executives go and there's like six kinds of wine and they're celebrating this meeting?

And it really was a good meeting.

And they had a three choice menu the first choice was triple a alberta beef with like asparagus or brussel sprouts something icky right the second one was chicken and the third one was fish i'd like to point to someone in the audience i won't say her name but generally when you're in places like santa fe or calgary fish should not be your first choice okay just just check it in with you okay right So who's going to get, what meal are you going to order?

AAA, Alberta, I mean, there's not even a question.

The problem is, is that the dumb fish course had crab cakes.

And I really wanted crab cake.

So I asked the waiter that evening, can I get the AAA Alberta beef, but can I substitute the crab cakes?

And the waiter said, no.

And I said, okay.

And he says, you know, there's just a certain amount of food we've prepared and the meals are prepared.

And so we just don't have enough extra food to substitute.

And I said, no problem at all.

I said, if you don't mind, though, would you tell the chef I'm the potato salad guy from lunch?

That's all I said.

They bring out the meals.

And I had a pile of crab cakes.

And the CEO turns to me and he said, how did you do that?

I said, well, I need to tell you a little story about lunch.

I've been kind of keeping it a secret.

it.

If we choose not to investigate or focus on minor events, cuts, slips, trips, falls, etc., and only on events that result in critical injury or fatality, can it be seen as not caring about hurting people?

Can I take a look at it and shut up?

So I think that's the wrong way to look at it.

And I think that sends the wrong message out to your organization.

I think what you want to tell your organization is that you really want to look at high information events more than you look at low information events.

And so help the organization understand that we're not looking at events based upon consequence or possible consequence.

We're actually looking at events based upon the context of the event.

Because you all know in this room that there are big accidents that have very little to teach us.

I mean, there's just not much to teach.

Something vibrated off the top of the rig.

It fell.

It hit hard.

I mean, I'm not sure.

I mean, we can learn from it for sure.

There are also little accidents that can teach us much.

And so I would really encourage you guys to rethink how you prioritize your potential to learn and really look at events and say, is there much to teach us here or is there not much to teach us here?

Now, that means you're going to have to do some kind of learning around the event early.

But if you're not doing event critiquing right now, I'd be really shocked and surprised.

Was that a no or yes?

I think that's good.

I mean, and just one thing is like, if investigations is how people feel cared for, you got a lot of other problems.

I mean, there's got, you know, thinking about if really the goal is to help people feel cared for, think about ways to give people more voice, you know, not through surveys, please.

And, you know, sort of other opportunities to share their experiences and their concerns and their fears than waiting until something bad happens.

Yeah, we had a lady that was about my age, mid-30s and, sorry, mid-60s, and she tripped on flat concrete, broke her kneecap in half.

Lost time accident.

I was the first responder on that call.

Where are my firefighters at?

It was like, oh my word, I don't know that I've seen somebody in that much pain before.

We got her out of there got her taken care of it was hard to even get her out in the hospital I mean in the ambulance she served so much it was a lost time accident it was a lost time accident, what do you think we did?

Took care of her knee.

Back in the day, it would be like, oh no, that's lost time.

You got to do something.

We got to start inspecting everybody's shoes when they come into work.

And we got to paint everything yellow and put a little sign up that says, know where your toes goes and write all this crap.

And we didn't do any of that.

We just took care of her knee.

We had a magnetic die clamp failed and dropped a 20,000 pound top plate in a die set right next to a guy's arm during setup.

Okay, that could have killed him.

Didn't even hurt him.

It was a new technology we're moving to, the magnetic die clamps.

We did deep, deep, deep operational learning.

And we found out we are not process capable of managing that technology.

Nobody even got hurt.

He was fine.

He was cleared by a few inches.

But that's the difference.

There's contextually rich, tons to learn.

The ladies tripped on the flat concrete.

I just think you take care of, Renee.

And actually, someone before this had a question, because right now they're doing like learning teams on seemingly everything, like any event that's happening and people are getting burned out.

And what we were talking about is that the place that you want to spend all your time and energy is a place that there's something to gain from spending all your time and energy, which means that there has to be something to learn, which is usually there's a lot of moving pieces, a lot of moving parts that you want to understand.

So we would call it high complexity.

But I like the – what term did you just say, Todd?

High learning?

What did – Oh, high potential learning.

High potential learning?

That or before, after potato salad.

High information.

We call them high information events, right?

High information.

Yeah, that's probably an easier way of thinking about it.

And you can tell the difference because when you go to talk to somebody who is involved in a low-information event, they don't even want to talk about it.

Well, there's not much to talk about.

Well, this happened.

But when Mark told that story about sometimes his friend Brian who fell and they were doing an investigation on him and he said sometimes people fall and then the instructor fell.

I mean, that's a really good example of a low-information event.

To me, and you guys all have to help me with this one, I really struggle with the whole idea of potential SIF.

I mean, I just do.

And the reason I do is because any accident, if the controls fail, can kill a person.

It's probably the majority of fatality.

Not the majority, but I've done an awful lot of fatality investigations in stairwells.

But most stairwells on your hazard assessments don't really hit the deck as potential SIFs because they're stairwells.

I mean, so I don't know how I feel about that.

I really struggle with that.

I don't have an answer because we have to have a way to look for significant events that we could learn from.

But I think a potential SIF, I don't know, it seems like if I was given the opportunity and didn't have a lot of time, I could talk the organization out of that being a potential SIF.

So I don't know.

I mean, I'm torn on it.

What do you think?

What do you think?

Well, yeah, but I don't want to because really the reward of talking them into doing stuff is that I have to do stuff.

Next question.

Do you want to read it?

When considering how to apply post-incident learning teams, what's the best way to determine when the organization should use them?

I'm concerned that without some definition that they may not be used consistently.

Initially, I thought about creating a flowchart to guide that decision.

I'm going to hand this to you.

So we made we live this one.

And the way we did it was in our production meeting in the morning, we just would look at the situation and go, that's worth learning about.

Another bee sting, another bug bite that turned into a recordable.

Yeah.

So we just, our boundaries around it were pretty straightforward.

We just said, let's talk about it as a leadership team.

If it's contextually rich or we don't really understand how it happened, or there's maybe a lot of stuff we can learn here.

If it's a bug bite, we had 30 bug bites one year, seven of them recordable.

You know what I stopped talking about?

Damn bug bites, right?

We had a honey farm across the street from us.

And I know you don't want to kill honey bees.

I saw the Bee Movie.

And so we just quit talking about it.

It was recordable.

I don't care.

But in a conversation and production meeting, that's what we use.

Now, different companies have actually written parameters.

I think it's fine.

Nothing wrong with that.

But I also think it's okay to just, as leaders and frontline leaders, say, whew, that's worth learning about.

I think that'd be worth digging into a little deeper.

Not a very scientific answer, but it sure works.

Post-learning team.

How do you recommend sharing what the team recommends to the leadership team?

There are times where we have a learning team, but then do not see the results afterwards.

Yeah, don't create more bureaucracy.

If you're short on bureaucracy, call me.

I still have a box left over from GE.

You can have it for free.

But, you know, Carmen, you used a lot of systems that you had in place already with your equipment, improvement things and all that, right?

So she's used that to track this stuff through.

But she also says something really important.

If we don't get stuff done, then people will be like, okay, well, don't ask me again.

So it goes also back to what's in my circle of control.

Let's do something.

We had one where the guy just needed a locking carabiner.

Said, can anybody help?

Right?

We had one where they just needed a buggy whip to be able to identify how close they were getting to the piece of equipment.

We had one where they needed a piece of tape on the ground.

Oh, no.

That was terrible.

So, three different work groups there could not get along.

It was amazing.

So, Andy and I led this one.

And they needed a piece of tape nice and straight on the ground to line the components up.

They could not figure out how to put the tape on it.

That's your job.

Nuh-uh.

That's facility.

Maintenance could do that.

They were arguing about it.

I wanted to say, give me the damn roll.

I'll put the tape down.

Andy and I decided we're not going to put the tape down.

Our goal, it may sound ridiculous.

This is what happens.

Our goal was to help them work through that problem of who's putting the tape on the ground.

That sounds silly and trivial, except that's how dysfunctional they were at that site.

Go where they're at.

So one point from Tuesday of the first day, we were talking a lot about transparency.

And I know of multiple workplaces that have kind of adopted a learning team process, but have serious situations where they have to sign confidentiality agreements, the people on the teams, that's not the way to do it.

Let's start there and then work backwards towards how to make this all transparent.

I'm personally a fan.

We do a lot of storyboarding of the learning team afterwards.

And the purpose of the storyboard is to tell the story.

And the story is not about people.

The story is about the work.

The story is about how the work was supported, what hindered the work.

But what's most important is that that story is written in a way that whether another worker reads it or a board member reads it, they can see themselves in the story.

Yeah.

And they can see the potential of other deeper systemic things that could exist in their areas.

And that's what drives it.

It's about, you know, that sharing and extending out further.

And I think you should also recognize that sometimes certain solutions that are produced don't work.

And that's okay.

And you just need to know when you need to go into a much better process.

Bob mentioned earlier that, you know, there are biases in these.

But in many cases, you go to the people who are doing the work and they absolutely know what the solution they need is.

Some problems are hairier that actually require innovation.

And that's when you need to go into a deeper innovation type process where you do some more critical thinking, where you spend more time.

You know, instead of producing multiple solution sets, you first produce multiple problem sets and you question those, the assumptions of the problem sets.

And then that's when you get to an innovative solution that no one had ever thought of before.

And so there might be some cases where your learning uncovers that you need to do more.

Not in most cases.

I think in most cases, the people doing the work know what they need to do.

But if it is a really hard, hairy problem, then you need to add some more rigor.

Yeah.

And I think that's a totally fair statement that oftentimes people will say, well, we defined the problem, but then like nobody knew how to solve it.

And then when we ask what the problem is, it's a problem that people have had for like 30 years that requires like a cross-functional group from multiple different activities to come together to come to some sort of consensus about that.

And you're like, well, yeah, that's not fair to have six people that you sat in a room for two hours be the only people that are there to solve the problem.

That is just not a fair way of doing it.

Now you can crowdsource solution sets.

You can get into an innovation space.

You can create a sub team that's going to go take a look at that and they can go through a cross function.

There's so many different ways of addressing it.

And for people who are asking, how is AI helping in this situation?

I can tell you, we recently did a learning team, came across a problem that had been a problem for, I don't know, Matt, do you remember how many years?

Decades?

Many, many, many years.

They had not solved it yet.

We defined the problem really well.

It was a technical problem in terms of being able to center something while another piece of material was rotating.

And they used ChatGPT to crowdsource a solution for it from all of the Internet and found within like a 20-minute search, they found a tool that they could purchase for like $200 to solve the problem.

I don't lose hands.

Nailed it.

I'm going to read the next question.

As a hub community, do you think we can move away from the terms like accountability and responsibility and only talk about ownership?

It feels like we are spending a lot of time trying to redefine a word that is no longer holding that meaning in our present day society.

I would say 100% I think you can move away from the word accountability and call it a practice of ownership.

But you first have to create the mindset shift away from accountability and discipline because there are so many ways.

It's a baggage-heavy word.

And in the redefining and the moving away, you have to own what accountability really is to be able to move into ownership.

Can I add just one thing?

Yes, please add.

So I love that answer.

And I think that it's very dependent upon your organization of where you might be able to do that and some organizations might not.

So it'd be wonderful to see a couple folks from this room right now come back and say, look at this really good success story and then share it with others who are struggling with those questions to show PAC at work what can happen when you move away from those terms.

I think there's a question that somebody wants you to...

Yeah, I think you keep pushing that down.

I don't think I need to read it.

I know that the question is, some regulators like OSHA seem to push things like accountability and discipline around some of the things within their work.

How do we deal with that or something like that?

I don't agree on this color OSHA.

So where I think the couple of places this really lies at OSHA is in the employee misconduct affirmative defense part of after a citation is issued and you're trying to say, well, Jim screwed up and that's why we got cited.

So don't cite us or remove the citation, withdraw the citation.

The other place that I think it shows up is within some of the programs like lockout, or part industrial vehicles where you're trying to demonstrate deviations in operations to show that you've done things like retraining when you've had that, that there is a process in place for that.

I know that this has been, over the years, really been spun up to say OSHA requires us to have a disciplinary program.

That's the case.

I think that in those, you know, a couple of specific examples, I'm sure there's some others, that there is something that says when somebody has done, you know, drives the fork truck into the I-beam, we probably should make sure they know how to drive the fork truck again.

That seems like a good logical step.

For the affirmative defense stuff after the citation, that gets into, you know, we've been really good in these three days of the term lawyer has only come up a couple of times, but that really comes into the, you know, what the lawyers have done to the practice of health and safety, in my opinion.

And it's something that I think there's a lot of room to show that there is retraining, counseling, other things that have been in place that discipline is not necessarily the only out.

And again, what we've been saying all week, there are some things that are HR issues and should be handled like HR issues, and those aren't safety.

In newly implemented initiatives or controls or processes that are intended to create capacity, but they're not getting put into place by the workers in the field.

Should we as leadership revisit these, or is this a more of a neglect issue for the employees not managing these controls?

I think one thing that we've done at Quantite, and when you think about this, when you start to put controls in place, what we do is we really identify the top three stickies, right, from the workers, giving us, hey, tell us what your top three stickies are, Right.

Then we pull them in and we say, now, let's go over some barriers that if put in place, we'll never we will never see this fatality again.

Right.

And so they're making their own controls for that task.

Then they're more willing to do it because they had a voice.

So if you're doing what we like to say is let's do capacity with the worker, not to the worker.

So I think that's what we have to think about is we're doing capacity with the worker, not to the workforce.

Kind of Tayloristic if we're doing it for them or to them, right?

But doing it with them is that back to that getting rid of that parent-child dynamic.

So I like it.

Yes.

So we're doing it with them.

We're pulling them in, right?

We're, hey man, tell me what the top three things are that can kill you if you go out there and do this task.

Now let's talk about what are some barriers that we could put in place that would be easy for you to do.

Cause if it's easy, they're going to do it, right?

And that would absolutely, if the release of energy does happen, would save you from being hurt.

And then they put it together and we stack hands.

We say, okay, guys, now you're, you told me, so now you're telling me now that we'll never have this event happen again that it hurts somebody.

I think I would add, I would just say, I mean, I'll just scream into the microphone, that if the workers aren't using the controls, you stopped analysis too early and whoever made the controls wasn't close enough to the problem.

I mean, I've never seen this as a problem because mostly I'm like you.

I let the workers tell me what they want.

Bob, When we did that tree trimmer thing, we had no idea what the control is.

But it's very funny because all the senior leadership was there.

And like I said, I'd really like a second climbing line.

I said, today is your lucky day.

You see all these new high-vis vests over here that have never been worn before?

That's the senior leadership team.

If you want the rope with gold strings and a diamond knot, you're going to get it today.

Just ask for it.

If our company is heavy hop, but is trending toward focusing on accident rates, how do we as middle management get it back on track?

I guess the question is why?

Why is it trending towards focusing on incident rates?

That's the first thing you need to find out.

So, is it customer pressure or like board pressure?

Okay, so this is happening because of customer pressure.

I mean, it's really interesting because the part that I think really is important here is the realization that there are opposing goals that exist simultaneously in your organization.

And that some of the tracking and trending they're doing on incident rates are important for customer interface or for regulatory interface, order of director's interface, but not terribly important for the workforce itself.

And so you may actually be keeping data that you show externally, but don't really spend a lot of time showing internally.

But I would, if this were my organization, I'd be super interested in learning what's going on.

because once you know what's going on, then you're in a little better place to just kind of tackle this problem.

So, because the bottom line is, at least with this, the most important middle management question you can ask is, what do we want our workforce to do with this data?

Because my entire career at Los Alamos, jump in, Michelle, I mean, you were there.

They would show us those TRC and DAR rates.

I had not the vaguest clue what to do with that data.

I mean, I think they wanted me to change history, but I don't have that power because if I did, I would have bought Apple really early.

So I have a quote to read from my former boss, but longtime friend, Doug Parker, who was the assistant secretary at OSHA in the last administration.

This was a quote from the ASSP conference, I guess last year's ASSP conference.

I was recently asked at a conference why we, OSHA, care so much about total incident rates, TRIR.

My response to the audience, I really think it's that you care more about that, about the total incident rates, not us, OSHA.

There were a couple other questions, but I thought that is the place to end.

With the quote from the OSHA administrator on you're more freaked out by total reportables than I am.

Always something to chew on.

Well, that was it.

That was open Q&A for 2025.

I'm glad you came along.

bong.

If you stayed this whole time, I'm proud of you.

Until then, learn something new every single day.

Have as much fun as you possibly can.

Be good to each other.

Be kind to each other.

And for goodness sakes, you guys.

Music.