LEARNING FROM NORMAL WORK
Find out WHERE and HOW you next accident can happen
Welcome Message and How to Maximize Impact
BEFORE Survey
Meet Kate
Learning From Incidents is Important but Limiting
Learning From Normal Work
Work Failure Rate
Things go Wrong for the Very Same Reasons that Things go Right
Kate Arrived at the Customer's Site
Chapter 1: Quick re-cap
Chapter 1: Apply it in Practice
Operational Constraints
Management's Constraints
Kate's Constraints
Why People Don't Follow Procedures
Kate's story - Entrance Gate Blocked by Equipment N
Workarounds
Kate's Workarounds
Chapter 2: Quick re-cap
Chapter 2: Apply it in practice
Work-as-Imagined and Work-as-Done (WAI / WAD)
WAI / WAD - Car Journey Example
WAI / WAD - Industrial Examples
Kate's WAI / WAD
Dependencies - It's Never Just One Person
Dependencies - Turbine Assembly Example
Kate's Dependendencies
Chapter 3: Quick re-cap
Chapter 3: Apply it in Practice
Chapters 1-3: Summary
What-You-Look-For-Is-What-You-Find (WYLFIWYF)
Kate's WYLFIWYF
Fundamental Attribution Error - Part 1
Fundamental Attribution Error - Part 2
Attribution Bias in Kate's Story
Chapter 4: Quick re-cap
Chapter 4: Apply it in Practice
Side Effects of Punishment
Side Effects of Punishment in Kate's Story
Psychological Safety
Test Psychological Safety Level in Your Team
Psychological Safety in Kate's Story
The Meaning of Accountability
What do you Want After an Accident?
Comparison of Accountability Frameworks
Types of Harm
Restorative Justice - Evidence of Effectiveness
Just Culture Frameworks
Site Manager Reflects on Usefulness of Accountability
Chapter 5: Quick Re-Cap
Chapter 5: Apply it in Practice
Chapters 4-5: Summary
Avoid the "WHY?" Question
Open Questions
TEDS Questions
How to Talk so Employees Open-Up
TEDS Questions in Kate's Story
Chapter 6: Quick Re-Cap
Chapter 6: Apply it in Practice
Leadership Engagement for Learning
Where to Start
Walk-Through / Talk-Through (WTTT)
How is WTTT Different From a Safety Conversation
WTTT Process and Form
To Use or Not to Use the Form
WTTT with Kate - Part 1
WTTT with Kate Filled Form - Part 1
WTTT Example
WTTT with Kate Part 2
WTTT with Kate Filled Form Part 2
WTTT Common Mistakes
Chapter 7: Quick Re-Cap
Chapter 7: Apply it in Practice
Introduction to Learning Teams Process
Learning Teams Phase 1
Learning Teams Phase 2 Session 1
Learning Teams Phase 2 Session 2
Learning Teams Phase 3
Learning Team Example 1
Learning Team Example 2
Implementation Examples
Implementation Roadmap
Chapter 9: Apply it in Practice
Closing Remarks
Dr Marcin Nazaruk