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Anything that is not an idea for a new course can go here!

Hi Rob, great job centralizing content and your insights on human performance. Something that I think organizations struggle with is after an incident, coaching leaders to separate the error from the outcome…easier said than done especially when a significant impact (people, environment, business loss) occurs and punitive measures are the norm to hold someone accountable. You can tell leaders that punishment for errors reduces moral, drives reporting underground, and will likely not improve future performance until your blue in the face, but the reality is many still believe a fear-based system will make people pay more attention the next time. Thus, as change agents bringing an understanding of the science of error to others in the organization, what would you suggest or which criteria of the deviation analysis process would you recommend to better determine whether an individual was truly aware that a "critical task" may have been involved that could have led to an irreversible outcome? I ask this because "consequence" does not appear in the deviation model although it can be an emotional driver for supervision and leadership to determine individual versus system accountabilities / corrective actions. Thanks!

Elliot – thanks for your question. It actually goes back to before the deviation analysis. Our experience has been that if you spend the time to define the elements (error, incident or event, deviation, violation, active error & latent error) you get the leaders educated. Step two is to get them to change their language and behavior around the human error concepts. Remember, we are not asking them to use the model yet, just to look at things differently (all things). Once they do that, then using the model for any perceived deviation makes sense to them because they have shifted their paradigm on errors versus outcomes. When they do this, they discover that the emotion around an outcome has no bearing on analyzing the drivers of the errors and deviations. This makes Deviation Analysis agnostic to the outcome. In future sessions, we are going to specifically address these topics and how to perform an effective Deviation Analysis. Thanks for the questions! Rob

Hello Rob, do you have a Robservation or Insight that addresses a typical response after a "poor" incident analysis…to Retrain the worker? I call them the Big 3 go-tos…Training, Procedures, and Communication…the tendency to focus on these. Are we truly improving the design of the system (a la Don Norman) or are we just following the path of least resistance and an illusion of control? Systems analysis and developing sustainable solutions take time, commitment, and resources…how to overcome challenges? thanks.