Counter Errorism

Get to know Rob Fisher:

Profile: linkedin.com/in/rob-fisher-8105293

Email: [email protected]

Website: improvewithfit.com

Rob's Book: Understanding Mental Models: Practically Applying Performance Modes, Systems 1&2, and GEMS

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Shoutouts

Procedure Professionals Association

FITonline Microlearnings: https://online.improvewithfit.com/

"Stew" on this: linkedin.com/in/stew-dunivan-36480834

Walking with "Wallace": linkedin.com/in/barry-wallace-1ab38b7

Taking it to the "Matt": linkedin.com/in/matt-schlapfer-262b7729

Follow this link to find some: Robservations

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NOTE: Yes, this episode could've been broken up into two or three episodes, but I'm hoping this is the easiest way for you to absorb this conversation. Rob was super generous to give us so much of his time AND to let us know where he was going to give us some coaching and when we should potentially pause (you'll hear it) the recording or editing... While I do edit some unrelated content out for time saving purposes, I think everyone who listens has the potential to learn right along with us in these types of conversations. We thank Rob for his professional candor and efforts at keeping us feeling psychologically safe. 

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In this conversation on the Counter Errorism podcast, Rob Fisher shares actionable strategies for improving procedure usability, capturing institutional knowledge, and transforming how leaders engage with frontline workers.

Here are the key lessons we learn from his approach:

• Changing Workforce Experience: Workers entering industry today often lack the mechanical background of previous generations (such as fixing bicycles or changing car tires). They lack an intuitive grasp of physical hazards and energy transfer.
• Avoid "Farming Out" Risk: Organizations cannot assume new hires or contractors automatically understand workplace hazards. Relying on quick classroom orientations or passing high-risk tasks off to third-party contractors ("stand the man in the van with his son") without diligent verification contributes to rising fatality and serious injury rates.

• Usability Over Technical Accuracy: Procedures are frequently technically accurate but practically unusable. When workers struggle, leaders often assume they just "refuse to follow procedures" rather than recognizing that the documentation is flawed.
• Bridging the Gap: Fisher reframes "work as imagined vs. work as done" into work as written vs. work as adapted. Leaders need to understand where and why workers must adapt written guidance to execute tasks safely and effectively.
• Removing Procedure Error Drivers: Vague phrases like "if applicable," "as needed," or ambiguous terms like "check," "ensure," and "verify" introduce confusion and drastically increase error rates.

• Replacing "Why" with Curiosity: Asking "why" puts workers on the defensive. Instead, leaders should use the TEDs framework to hold constructive engagements:
  • Tell me (what doesn't make sense)
  • Explain to me (what is different than expected)
  • Describe to me (what makes this task more difficult)
  • Show me (how our systems increase risk)
• Separating Engagements from Observations: Leaders should separate behavioral observations (watching workers) from true engagements (two-way conversations about system conditions and values). This removes the "policing" atmosphere and allows leaders to learn about operational reality.

• The Flaws of STAR and Peer Checks: Traditional tools like STAR (Stop, Think, Act, Review) or peer checks often fail in practice; peer checks can inadvertently introduce four new error traps: distraction, time pressure, stress, and overconfidence.
• Slowing the Brain Down: Fisher advocates for Verbalized Point and Touch (VPT). Speaking the action aloud and physically pointing to/touching the component forces the brain to slow down to the exact speed at which the body performs, filing the action into memory and reducing error rates significantly.

• Preserving Expert Wisdom: As senior workers near retirement, organizations should not try to cram decades of rationale directly into procedures, which makes them overly complex.
• Training and Reference Materials (TNRM): Instead, pull experienced workers off-shift to create micro-recordings explaining how to execute complex steps. These recordings are stored in Training and Reference Materials (TNRM), capturing individual expertise so the organization doesn't lose critical knowledge.

• Newest Qualified User: Procedures should be written to the standard of the newest qualified user—meaning anyone who reaches baseline qualification should be able to complete the task as written with little or no supervision.
• Misuse of "Skill of the Craft": "Skill of the craft" should never be used as a catch-all excuse to skip written guidance on high-hazard tasks involving hazardous energy or excavation.

• Re-Framing Rules: Instead of throwing away life-saving rules or decrying them as "safety clutter" without evaluating their intent, organizations should remove punitive termination clauses and reframe them as life-preserving principles.

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Please check out the amazing people doing amazing things on these podcasts we listen to and love:

• Leading Safely Podcast with Georgina Poole
• Were We Lucky, or Were We Good Podcast with Steve Smith
• The Safety Bros with Brad and Dan Ruiz
• Punk Rock Safety with Dr. Ben Goodheart, Dr. Dave Provan, and Dr. Ron Gantt
• Counter-Errorism in Diving: Applying Human Factors to Diving with Gareth Lock
• How Did It Make Sense? with Gareth Lock
• The HOP Nerd with Sam Goodman
• A HOP Podcast (With No Name) with Andrea Baker and Matt Florio
• Health & Safety Conversations with Tom Bourne
• Pre-Accident Investigations with Todd Conklin
• Safety on Tap with Andrew Barrett
• Hop Into Action with Brent Sutton
• The Safety of Work with Dr. David Provan and Dr. Drew Rae
• Not Just Another Damn Safety Podcast with Steve Scott 
• Illusion of Safety with Allison Short, Joshua Russell, and Gabe Encarnacion
• Be Empowered with Dr. Santoshi Billakota and Dr. Shahla Moghbel
• (Not HOP-related, but an AMAZING untold history podcast) The Missing Chapter Podcast with Philip Horrender and Phil Schoff

Get to know Todd Conklin

Profile: linkedin.com/in/todd-conklin-64b8a8a

Email: [email protected]

Website: https://preaccidentpodcast.podbean.com/

Click here for a little about bear school

Unexpected love and shout outs to:
Clive Lloyd (future guest) and Steve Harvey (ep.6), The Punk Rock Safety fellas (Ben Goodheart ep.2, Ron Gantt ep.9, and David Provan ep.20) - Podcast title courtesy of the brilliant Gareth Lock (ep.7) - Psyche Safety guru, Amy Edmundson (maybe future ;) guest?) HRO Wildfire guru, David Christenson (Human Performance Tools Podcast co-host from many years ago starting ep.10) - and even the recently late Queen of Sweetness, Dolly Parton.

According to AI, the official "Pre-Accident Investigation Podcast" started in April 2015.

• Creator: Todd Conklin
  • Launch Date: April 12, 2015 (Episode 1)
• Focus: Human performance, systems safety, and workplace safety culture

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Strange info from the intro:

Click here for the true story of the cocaine bear

Click here for the false story of the diver dropped on a wildfire

Navajo Dam and Reservoir Specs

• Normal Operating Depth: 381.6 feet at the dam.
• Maximum Structural Height: 402 feet (123 m).
• Maximum Lake Depth: Reaches approximately 396 to 400 feet when full.
• Current Water Level: The reservoir level fluctuates based on seasonal use and inflows (sitting around 74.5 feet below full pool).

For more info on the CHOL (Community of Human and Organizational Learning) click here.

And now......

Todd Conklin outlines how organizational reliability and human performance depend on how leadership perceives operations, reacts to failure, and approaches learning.

Here are the key lessons we learn from his approach:

• The Ultimate Gatekeepers: Real organizational change cannot succeed unless time, energy, and resources are invested in changing how leaders think. Leaders act as the primary gatekeepers to creating a sustainable culture of safety and reliability.
• The Enemy of the Question is the Answer: Leaders face two main obstacles: busy schedules and the assumption that they already understand the issues. The moment a boss believes they already know what the problem is, their necessity to learn vanishes, and they immediately shift into "fixing" mode.
• Trust is Leadership's Responsibility: Sharing an anecdote about a chocolate company whose workers lacked trust in management, Conklin points out that workers distrusting senior leadership is not a worker problem—it is a leadership problem that only leadership can fix.

• A Fundamental Philosophical Shift: The single most important transformation an organization can make is moving away from seeing the worker as a problem to be fixed, and instead recognizing the worker as the essential source of solutions.
• Language Reflects Culture: The language leaders use to describe their workforce reveals whether they view workers as failure points or as operational experts.

• The Investigation's Job is to Learn: An investigation's sole purpose is to learn, explain, and describe how an event occurred—not to rush out solutions. Rushing to fix creates confirmation bias, leading investigators to "fall in love" with a pet problem rather than understanding the full context.
• Judgments of Need: Drawing on Department of Energy (DOE) practices, investigations should issue Judgments of Need (identifying weak areas or lack of risk control) and let programmatic and operational owners design the corrective actions. Forcing solutions down on operational teams from an ivory tower is insulting and ineffective.
• Eliminating "Safety Clutter": Rushing to fix events results in administrative clutter—such as mandatory procedure retraining or adding signs—which rarely stops recurrence and adds unnecessary procedural burden.

• "Cause" is Made Up: Labeling a cause (e.g., "spark plus fuel caused an explosion") merely describes the laws of physics rather than operational reality. The richer question is asking how the system put workers in a position where sparks and fuel were exposed to each other.
• Extent of Condition: Organizations should evaluate where else across the facility similar conditions exist (e.g., high production pressure, turnover, untethered equipment).
• Eliminate the Need for Risk: In a rail shop fatality investigation involving cranes lifting heavy wheel assemblies 19 times, asking "why do you lift these?" revealed they had cranes simply because they were installed years ago. By switching to rolling the assemblies on tracks using an existing dolly, they eliminated the lifting hazard entirely.

• The Flaw of Culpability Matrices: Flowcharts and culpability matrices are popular because they promise an easy algorithm to remove hard human decisions, but they inherently assume culpability/guilt from the start.
• The Substitution Test & Psychological Candor: Rather than using rigid flowcharts, enlightened leaders rely on the substitution test ("Would a reasonable worker given the same context, time, and conditions do the same thing?"). This requires psychological candor—the willingness of workforce members to speak painful truths without fear.
• Relentless Curiosity: Quoting business scholar Amy Edmondson, Conklin stresses that true learning organizations are defined by relentless curiosity. When curiosity leaves an organization, learning stops and risk increases.
• Welcoming Differing Professional Opinions (DPOs): Advanced science-forward organizations strengthen investigations by actively encouraging alternative theories and peer reviews (or Differing Professional Opinions) to challenge assumptions before finalizing reports.

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For those extra curious: Nuclear Power typically uses a "Corrective Action Review Board" for higher order Causal Analysis to ensure CAs reflect best effort to fixing problems:

Core Responsibilities of a CARB

• Reviewing Event Evaluations: Assessing Root Cause Analyses (RCAs) and Apparent Cause Evaluations (ACEs) for quality, depth, and accuracy.
• Approving Corrective Actions: Ensuring proposed fixes directly address the underlying causes of a problem to prevent recurrence.
• Monitoring Station Trends: Identifying adverse performance trends or recurring failures across different plant departments.
• Enforcing Accountability: Holding department managers accountable for the timely completion of critical safety and maintenance actions.

Typical Board Composition

The board is comprised of senior station leadership to ensure cross-departmental alignment and authority.

• Plant Manager / Director of Operations (Often serves as the CARB Chairman)
• Operations Manager
• Maintenance Manager
• Engineering Manager
• Regulatory Affairs / Compliance Manager
• Performance Improvement / CAP Manager

Key Benefits

• Nuclear Safety Culture: Reinforces a conservative decision-making approach by subjecting problem-solving to multi-disciplined peer review.
• Resource Prioritization: Ensures plant resources are directed toward fixing the most risk-significant issues first.
• Regulatory Compliance: Demonstrates to oversight bodies, like the Nuclear Regulatory Commission (NRC) in the US, that the utility effectively self-regulates and corrects its own deficiencies.

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Please check out the amazing people doing amazing things on these podcasts we listen to and love:

• Leading Safely Podcast with Georgina Poole
• Were We Lucky, or Were We Good Podcast with Steve Smith
• The Safety Bros with Brad and Dan Ruiz
• Punk Rock Safety with Dr. Ben Goodheart, Dr. Dave Provan, and Dr. Ron Gantt
• Counter-Errorism in Diving: Applying Human Factors to Diving with Gareth Lock
• How Did It Make Sense? with Gareth Lock
• The HOP Nerd with Sam Goodman
• A HOP Podcast (With No Name) with Andrea Baker and Matt Florio
• Health & Safety Conversations with Tom Bourne
• Pre-Accident Investigations with Todd Conklin
• Safety on Tap with Andrew Barrett
• Hop Into Action with Brent Sutton
• The Safety of Work with Dr. David Provan and Dr. Drew Rae
• Illusion of Safety with Allison Short, Joshua Russell, and Gabe Encarnacion
• Be Empowered with Dr. Santoshi Billakota and Dr. Shahla Moghbel
• (Not HOP-related, but an AMAZING untold history podcast) The Missing Chapter Podcast with Philip Horrender and Phil Schoff

Get to know Danielle Ford:

linkedin.com/in/danielle-ford-cptd

Email: [email protected]

Danielle's publication: Rhythm and Revelation

In her conversation on the Counter Errorism podcast, Danielle Ford shares how organizations can bridge the gaps between training, procedures, and investigations. She challenges conventional safety responses and offers a highly practical roadmap for embedding continuous learning into normal operations.

Here are the key lessons we learn from her:

When an incident occurs, organizations frequently default to "we need to retrain the worker" because it is the fastest, easiest way to satisfy regulators, boards, or executives. Ford argues that retraining is rarely the correct answer. Instead, she advocates for using a task-focused approach, like the Systematic Approach to Training (SAT), to isolate the specific failure point. By partnering with the frontline workers who perform the task daily and asking, "Why didn't it work for you today?", organizations can design far more effective, lower-burden solutions—such as improved signage or targeted job aids—rather than forcing employees through redundant training programs.

To stop the constant cycle of immediate retraining requests, Ford’s organization has started using Microsoft Copilot to build an AI bot. The bot walks operational partners through a standard series of questions to help them determine if retraining is actually necessary. By immediately flagging alternative solutions (like updating a procedure or a job aid), the bot acts as an automated filter, saving the training department from spending hours upfront proving that retraining is not the right tool for the job.

To get workers to honestly share operational risks before an incident occurs, leaders must actively build trust. Ford explains that "managing by walking around" is one of the most effective ways to establish psychological safety. When a supervisor's presence in the workspace is normal and routine, employees stop viewing visits as "gotcha" moments. Instead, it opens the door for informal, casual dialogues where real risks and potential failures naturally bubble up and can be proactively solved.

Human nature naturally draws us to focus on the negative, but Ford emphasizes that you cannot build a learning culture if every mistake is treated like a courtroom trial. Leaders must redirect conversations toward the "normalization of excellence". This means having regular, supportive conversations with workers about what makes them high performers, how they execute work consistently, and how they successfully avoid the challenges their peers face.

To prevent hard-won operational insights from getting lost in the shuffle, Ford recommends using quarterly operational "forums" to share high-performance practices across shifts (such as sharing day-shift insights with the night crew). Her organization ensures these learnings are actually implemented by tasking an administrative "special projects" team to track the progress on a 30-60-90 day schedule. These tracked learnings populate a centralized dashboard, allowing the organization to revisit, update, and refine best practices as new nuances arise.

When the frontline brings innovative ideas to a learning forum that management cannot implement due to budget, regulatory boundaries, or strategic roadmaps, the worst thing a leader can do is ignore them. Ford advises that leaders must be completely transparent about the organization's guardrails. When a leader honestly and candidly explains, "This is a great idea, but we cannot do it today because of these specific parameters," workers accept the feedback and feel valued because they were genuinely heard, preventing post-meeting resentment.

When a major incident occurs, a worker's immediate fear is often that their career is over. Ford highlights that leaders must use their emotional quotient (EQ) to support the worker's psyche and self-worth. Rather than immediately standing them down—which feels like a punishment to the worker and signals to the rest of the team that they should hide their mistakes—leaders should focus on helping the individual recover and ask what they need to show up and function safely.

🤖 It is fascinating to contrast Danielle’s practical use of an AI bot to filter training needs with Bob Latino's warnings (from Episode 23) about AI's severe blind spots in Root Cause Analysis.

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Joe Hauglie (pronounced "Hoag-Lee"):

linkedin.com/in/jhauglie

Email: [email protected]

An article about Joe: https://www.wellsaid.io/resources/blog/arizonas-largest-electric-utility-significantly-boosts-safety-training-engagement-with-wellsaid

Joe Hauglie emphasizes that human and organizational performance is fundamentally a profession built on shared knowledge. Rather than relying solely on our own experiences and making every mistake ourselves, we must proactively learn from the mistakes of others to recognize error traps before they lead to failure. For example, traditional power plant operators have decades of shared knowledge to rely on when a gauge fluctuates, whereas technicians in newer fields, like renewable energy, might only have a handwritten checklist from the previous shift to guide them.

To help frontline workers systematically identify and manage these error traps, Hauglie advocates for using tools like the "energy wheel" during pre-job briefs and two-minute drills. Instead of relying entirely on an individual's imagination to spot danger, the energy wheel prompts teams to systematically identify various forms of hazardous energy—such as chemical, electrical, or even unexpected sources like sound. Furthermore, it forces teams to re-evaluate their environment when returning from a break to see if changing variables, such as sudden rain, have altered their risk profile.

When discussing hazard detection and prevention, Hauglie warns about the double-edged sword of modern technology and automation. Tools like blind-spot sensors in cars or artificial intelligence are increasingly taking over the responsibility of detecting hazards for us. While this can free up our attention, relying too heavily on automated systems inadvertently creates new human vulnerabilities. If a worker becomes accustomed to technology acting as their detection system, they may lose their baseline situational awareness and face a dangerous new error trap when that technology is absent, modified, or fails. Ultimately, Hauglie challenges leaders to consider where technology gives us a lift, and what type of hazard detection human workers still need to actively own.

Finally, Hauglie highlights the importance of integrating these safety and performance principles beyond traditional field operations and into everyday corporate environments. Whether it is catching administrative software settings that cause scheduling errors or running a pre-job brief for a corporate volunteer event, taking the time to pause, ask what could go wrong, and adjust systems based on recent missteps allows an organization to continuously learn and improve from normal work.

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Aaron Potash:

Profile: https://www.linkedin.com/in/aaronpotash/

Website: https://www.originaloaktowndivers.com/

Recent Article (video link at the bottom of the article): Windup in the Bay 2026

Email: [email protected]

In his conversation on the Counter Errorism podcast, Aaron Potash emphasizes the critical role of cultivating genuine empathy, curiosity, and vulnerability to build psychological safety and drive operational excellence.

Here are the key lessons we learn from his approach:

Cultivating Empathy Over Compliance

Potash explains that safety professionals must move away from a traditional compliance mindset—where they act as the "subject matter expert" dictating rules—and instead become genuinely intrigued by a worker's actual experience. By shifting to a stance of curiosity and asking, "what is that like for you?", leaders can build the trust necessary for workers to freely share their challenges.

Humble Inquiry and Positioning as a Learner

To disarm workers, especially highly trained experts, Potash utilizes humble inquiry, often starting conversations with phrases like, "Forgive me, may I ask about something?". By intentionally positioning himself "below" the worker and acting as a learner rather than a policing expert, he removes the threat of judgment and invites the worker to become the teacher.

Vulnerability and Creating Space to Fail

Drawing from his experience as a scuba diving instructor, Potash highlights the importance of leaders sharing their own mistakes, weaknesses, and errors with their students. This vulnerability proves that the leader is fallible and actively helps create a safe environment where people have the space to fail, make mistakes, and continuously strive to "be better than yesterday".

The "King for a Day" Approach

To quickly uncover hidden frontline challenges, Potash advocates for asking workers one simple question: "If you could be king for a day, what would you make better about this?". He shares an example of asking this question about a seemingly simple stick used for sounding the ground, which sparked an impromptu "mini learning team" conversation. This specific question gave the workers the space to reveal the tool's complex history, hidden functions, and future design modifications that leadership was completely unaware of.

The Illusion of the "Same Side"

Potash challenges the common safety cliché that everyone in a company is "on the same side". He points out that different departments often have competing KPIs that inadvertently interfere with the people actually getting the work done in the field. Ultimately, empathy is required to translate these conflicting organizational requirements into systems that actually support the frontline work.

Mentions in this episode:

Humble Inquiry, 3rd Edition: The Gentle Art of Asking Instead of Telling (The Humble Leadership Series)

Other podcasts Aaron's on:

Safety Labs w Mary Conquest: Helping Workers Make Safer Decisions with Aaron Potash

Gareth Lock's How did it make sense?

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Dr. Martha Acosta:

Profile: https://www.linkedin.com/in/martha-acosta-ed-d-7293ba4/

Website: martica.com (Company)  marthaacosta.com (Personal)

Email: [email protected]

In her conversation on the Counter Errorism podcast, Martha Acosta shares profound insights on transforming how organizations learn, emphasizing that leaders must shift from trying to "fix the worker" to fostering a genuine "performance culture" that embraces continuous learning and experimentation.

Here are the key lessons we learn from her approach:

Moving from a Fixed to a Growth Mindset

Organizations historically operated under a "fixed mindset," using behavioral models to try to "fix" workers, operating under the illusion that a person or a system could reach a point of absolute perfection where mistakes are impossible. Acosta advocates for adopting a "growth mindset," which is the foundational belief that people and environments must be continuously developed.

Coaching Through Inquiry (The GROW Model)

Acosta believes the single most effective leadership practice for creating a learning organization is coaching. However, this does not mean acting like a high school volleyball coach who just tells people what they did wrong and barks orders. True coaching uses humble inquiry to help teams discover motivations and options. She frames this using the GROW model: Goals (Shared Purpose), Reality, Options, and Way forward.

Uniting Experts with a Shared Purpose (Goals)

When dealing with ad-hoc groups of highly specialized experts, individuals can easily become compartmentalized, deferring only to their specific knowledge silos. Furthermore, team members often have conflicting individual goals (like wanting overtime vs. avoiding it). A leader's job is to establish a clear "shared purpose" so everyone knows exactly why they are doing the work, which pulls the diverse expertise together.

Exploring the Context (Reality) via Humble Inquiry

Rather than managing safety solely by reacting to accidents after the fact, leaders should continuously observe the "reality" of normal work to catch systemic drift early. To truly understand this reality, leaders must utilize humble inquiry. Instead of acting like a policeman looking for procedural compliance, leaders should use disarming phrases like "help me understand," "walk me through this," or "paint me the picture," which invites workers to share their actual context without fear of giving the "wrong" answer.

Problem Solving vs. Solution Finding (Options)

A massive trap organizations fall into is "solution finding"—impatiently pulling past solutions out of their pockets to quickly apply to new problems. In volatile environments, assuming the current reality perfectly matches the past is dangerous. Real problem solving requires pausing to generate multiple different options and hypotheses before rushing to fix things. Acosta even suggests using AI as a tool to put on different "thinking hats" and generate diverse alternatives that humans often skip because it takes too much time.

The Way Forward Requires Planning for Failure

In highly innovative or hazardous environments, a true performance culture is a learning culture. When you commit to a "way forward" on something you haven't done before, it is essentially an experiment. Because the hypothesis might be wrong, leaders must actively plan for failure—ensuring hazards are mitigated so that the team can fail safely, learn from the experiment, and prevent unbearable outcomes.

Unlearning and Recognizing that Context Drives Behavior

When workers make mistakes, leaders must realize that management creates the context in which those decisions are made. Instead of blaming the worker, leaders must evaluate whether the context they provided—through lacking resources, confusing procedures, or poor communication—made the worker's actions make sense at the time. Furthermore, to adapt to new contexts and successfully improve, organizations have to be willing to do the hard work of "unlearning" their deeply ingrained habits.

Mentions in this episode:

SAFETY CAPACITY: Leadership Practices for Failing Safely by Martha L. Acosta Ed.D. (Author), Todd Conklin Ph.D. (Foreword) 

Six Thinking Hats by Edward de Bono (Author) 

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Bob Latino:

Profile: linkedin.com/in/boblatino

Website: prelical.com

Email: [email protected]

In his conversation on the Counter Errorism podcast, Bob Latino shares valuable insights into defect elimination, system reliability, and the evolving role of technology in incident investigations.

Here are the key lessons we learn from his approach:

Experiential Learning and "The Manufacturing Game"

Latino advocates for using experiential learning to teach defect elimination, specifically highlighting a simulation called the "Manufacturing Game" originally developed at DuPont. While leaders are often initially skeptical about paying their employees to "play a board game," the exercise effectively models the complex system dynamics of a real plant over a day and a half to two days. The simulation throws real-world variables at the players—such as safety violations, defective parts, and customer complaints—and proves that an organization will only survive if its operations, maintenance, and support services learn how to effectively communicate with one another. Because workers actually experience these lessons, the principles become highly memorable and impactful.

The Link Between Reliability and Process Safety

Latino highlights a strong, historically proven correlation between equipment reliability and process safety. He explains that when a plant achieves "steady state operation" through good preventive and predictive maintenance, it experiences far fewer unexpected upsets. Consequently, workers are much less likely to be forced into dangerous, energized areas to address sudden mechanical failures, which inherently keeps them safer.

The Limits of AI in Root Cause Analysis (RCA)

When looking at the future of incident investigations, Latino warns about the severe blind spots of Artificial Intelligence. While AI is excellent at analyzing the mechanical "physics of failure" (such as detailing the various ways a specific bearing might break), it completely lacks the critical real-world context of an event. AI cannot comprehend the nuances of complex human decision-making or flawed organizational systems—such as a worker making a mistake because they were forced to use an obsolete procedure that management failed to update after installing new technology. Latino advises that investigation teams should exhaust their own human knowledge and understanding of the context first before turning to AI, rather than using it merely as a shortcut to rush a report by the end of a shift.

Mentions in this episode:

The Manufacturing Game

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Nikki Knapp:

Profile: https://www.linkedin.com/in/nicoleknapp/

Email: [email protected]

In her conversation on the Counter Errorism podcast, Nikki Knapp shares practical, creative approaches to teaching Human and Organizational Performance (HOP) and emphasizes the critical importance of human connection.

Here are the key lessons we learn from her approach:

Relationships as the Foundation of HOP

Knapp stresses that you cannot prevent, detect, or correct errors until people feel comfortable talking to you. If a safety professional lacks a relationship with workers, leaders, or engineers, they have zero influence and cannot advocate for meaningful change. To build this trust and psychological safety, she intentionally uses vulnerability—sharing her own mistakes and off-the-wall personal stories to disarm people and prove she is just as fallible as they are.

Integration vs. Implementation

Many leaders simply want a checklist or procedure to formally "implement" HOP as a standard safety program. However, Knapp points out that you cannot mandate or implement a relationship. Because every person and organization is unique, HOP principles must be organically integrated into everyday interactions and systems rather than blindly implemented out of a box.

Using Games for Experiential Learning

To make dry subjects (like error precursors or radiation training) engaging, Knapp uses hands-on games to crack people's shells. Some of her practical exercises include:

Celebrating Success and "Normal Work"

Organizations are notoriously quick to dissect what went wrong, but they rarely take the time to celebrate "normal work"—the days when everything goes right and no one gets hurt. Knapp advocates for pausing to actually celebrate successes before picking apart minor failures. She also champions peer-to-peer recognition systems (like Bucket List or Kudos) where workers can publicly reward each other with points for good catches, safety improvements, and helpful behavior, which also gives leaders visibility into the good things happening on the floor.

Care Before Correction

When an incident does happen, leaders often default to their strategic brains, immediately asking how the event could have been prevented. Knapp actively coaches leaders to pause and ensure that the very first question asked in any post-event meeting is, "How are they doing?", ensuring that the human being and their family are cared for before any operational learning takes place.

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Mitch Schwarz:

Profile https://www.linkedin.com/in/mitch-schwarz-139538165/

Email: https://www.safesetehs.com/contactus

Website: https://www.indeavor.com

In his conversation on the Counter Errorism podcast, Mitch Schwarz highlights a critical but often overlooked operational vulnerability: the "frontline scheduling capacity gap." He explains how perfectly planned work (the theoretical "black line") frequently falls apart right before a shift starts, placing a massive, unmanaged burden on frontline leaders.

Here are the key lessons we learn from his approach:

The Chaos of the "Golden Hour" Schwarz points out that the hour before a shift begins is a highly pressurized "golden hour" where everyday variability—like a sick child or a flat tire—can suddenly wreck a meticulously planned schedule. To fill these last-minute gaps, supervisors are often forced to juggle Excel spreadsheets, tribal knowledge, or even easily erased whiteboards to match worker qualifications with complex union and fatigue rules. This heavy administrative burden completely drains the supervisor's "adaptive capacity," pulling them away from actually coaching their teams on the front line.

Uncovering Upstream Root Causes When safety incidents occur, root cause analyses rarely trace the problem back far enough to this initial scheduling chaos. Investigators often miss the fact that a worker made a mistake because they were severely fatigued after being held over for five extra hours to cover a call-out, or because they were suddenly thrust into a crew they had never worked with before just to fill a gap.

Capacity as an Insurance Policy Schwarz brilliantly frames operational capacity—the crucial margin for error in a system—as an insurance policy. You don't need capacity until something goes wrong, but you absolutely cannot buy it after an accident has already happened. He stresses that an organization's capacity to fail safely is often built or entirely destroyed right at the point of staffing, before the work even begins.

Reducing Grievances Through Transparency By utilizing technology to automate the scheduling process, organizations can merge disparate rules and training matrices into one seamless system. Crucially, this gives frontline workers visibility into their schedules and overtime opportunities via an app. This transparency levels the playing field, prevents supervisors from only picking their "buddies" for overtime, and significantly reduces worker grievances and turnover.

A Practical Exercise for HOP Practitioners For organizations wanting to expose these hidden issues, Schwarz offers a simple, actionable takeaway: gather a learning team of your frontline supervisors and ask them one question: "What do we do with a last-minute call out right now?". He notes that this single question will immediately uncover massive amounts of operational pain and friction that rarely make it up to upper management.

Please check out the amazing people doing amazing things on these podcasts we listen to and love:

Get to know Dr. David Provan:

Profile linkedin.com/in/david-provan-forgeworks      Email: [email protected]

Website: https://www.forgeworks.com/                        Get his book: A Field Guide to Safety Professional Practice

Podcast Co-host: The Safety of Work                            Podcast Co-host: Punk Rock Safety

Dave Provan shares powerful insights on bridging the massive gap between management and the frontline, emphasizing that true safety is found in operations, not paperwork.

Here are the key lessons we learn from his approach:

Compressing the Organization & Genuine Curiosity

Provan emphasizes the critical need to "compress the organization" by ensuring leaders are deeply connected to the reality of frontline work. To do this effectively, leaders must set aside their assumptions and tap into genuine humility and curiosity. He suggests leaders consider an Undercover Boss analogy—asking themselves how surprised they would be if they actually had to work on their own frontline.

Face-to-Work vs. Face-to-Screen Time

A major barrier to this connection is how leaders spend their time. Provan breaks a supervisor's day into three categories: face-to-screen, face-to-face (meetings), and face-to-work. He points out the alarming reality that many supervisors spend up to 75% of their day "face-to-screen" and only 2% to 5% (roughly 8 to 10 minutes a day) physically at the work front observing the jobs they are responsible for. He strongly echoes the sentiment that a true "open door policy" means the manager's door is open because they are actively out of their office.

Safety is a Verb, Not a Noun (Paperwork vs. Practice)

Many industries still mistakenly believe that safety is defined by the forms filled out and the procedures followed. Provan illustrates this with a story about a pool construction crew who worked with incredible communication, pauses, and problem-solving, but felt they weren't "doing safety" simply because they lacked formal paperwork. Provan reminds us that safety is about verbs, not nouns—it is about having the capability, tools, time, and support to actually do the work well.

Stop Wasting Time on Terminology

Organizations often waste massive amounts of "organizational airspace" debating trivial terminology—such as spending half a day arguing whether a program should be called "Stop Work," "Pause Work," or "Timeout for Safety". Provan argues that splitting hairs over language avoids the actual hard work. Instead, leaders should focus purely on the outcome: making it easy and culturally acceptable for workers to reach out for help without feeling like they are bothering a busy supervisor.

The Hypocrisy of Accountability

Provan highlights a stark double standard in how companies view accountability. When he proposed creating a set of "life-saving leadership rules" for management—where leaders could be formally sanctioned or fired for failing to support the frontline—the organization thought the idea was entirely ridiculous. Yet, they found the exact same punitive concept perfectly acceptable when applied to the workers.

Reframing the Question: "Better" instead of "Safer"

Finally, Provan shares a brilliant tactic for getting better feedback from the frontline. He advises against asking workers, "How can we make this job safer?" because workers often conflate "safer" with restrictive checklists, more training, or extra procedures. Instead, leaders should simply ask, "How could we make this work better?". This immediately prompts workers to discuss improvements in quality, speed, tools, and resources—all of which inherently fix safety hazards along the way.

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