How did it make sense?

"If only they'd followed the rules"—a phrase we hear all too often in health and safety. But what if the story isn't that simple? In this episode of How Did It Make Sense?, I chat with safety expert Stephen Harvey to uncover the second story—the deeper, more complex reality behind incidents. Stephen shares his journey from mechanic to safety advocate after a near-fatal workplace accident and reflects on a tragic mining fatality where a worker’s decision-making was shaped by experience, pressures, and the realities of the job—not just disregard for rules. We also tackle the myth of stop-work authority, why humour is a powerful safety tool, and how real change comes from leaders who listen, not just enforce. Resources recommended: The Field Guide to Understanding Human Error – Sidney Dekker Pre-Accident Investigation Podcast – Todd Conklin Disastercast – Drew Rae (a must-listen, you can find on Itunes) Connect with Stephen Harvey: Find Stephen on LinkedIn and check out his YouTube and Instagram (@SafetyBhoy) for insights, stories, and a bit of humour in safety. Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

If we don’t test all the code, entire global systems can go down—and it’s not as simple as it seems. In this episode I speak with Colette Alexander, Director of Site Reliability Engineering at HashiCorp, about software failures, risk in software testing, and resilience in engineering. They dive deep into the CrowdStrike outage, exploring why skipping tests in software releases can have catastrophic effects. But it’s not just about a software company making a bad call—it's about the trade-off between speed and safety, how software engineers balance risk, and why testing everything isn’t always an option. Colette shares insights from the world of site reliability engineering (SRE), drawing parallels with aviation, space disasters like Challenger, and even the psychology of teamwork in rock bands. This episode is a must-listen for anyone in software development, DevOps, cybersecurity, or engineering leadership who wants to understand the real-world impact of software testing decisions. Topics Covered: ✔ The CrowdStrike outage: What went wrong? ✔ The hidden risks of incomplete software testing ✔ How software engineers balance speed, security, and resilience ✔ The psychological and organizational pressures behind failures ✔ Lessons from music, space disasters, and high-risk industries Resources Recommended: How Complex Systems Fail – Richard Cook Mission Improbable: Using Fantasy Documents to Tame Disaster – Lee Clarke Fantasy Documents and Disaster: A Case Study of the Long Island Nuclear Plant – Lee Clarke & Charles Perrow Beyond Blame: Learning From Failure and Success – Dave Zwieback Find Colette Here: Podcast: This Is Fine Podcast Website: thisisfinepod.com Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here  

Learn how engineers and leaders turn breakdowns into breakthroughs to foster learning, resilience, and innovation. Today I am joined by Chad Todd a seasoned SRE Manager at CrowdStrike with over 20 years of experience in the tech industry. Chad shares with us a a detailed account of a recent system incident, breaking it into the first story—what happened at the surface—and the second story, which uncovers the deeper, systemic factors and decision-making processes involved. The conversation highlights the challenges of maintaining complex IT systems, the value of fostering a culture of learning from incidents, and the role of teamwork in troubleshooting under pressure. They discuss the importance of database maintenance, how latent conditions contribute to failures, and the art of adaptive problem-solving. Recommended Resources: A Tale of Two Stories: Contrasting Views of Patient Safety by Richard Cook and David Woods. How Complex Systems Fail by Richard Cook. Richard Cook’s presentation at the Velocity Conference. Rasmussen’s framework on safety and resilience. You can connect with Chad Todd on LinkedIn or on BlueSky and Twitter (X) @CTodKicker1 Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here  

In this episode, I chat to Human Organizational Performance Manager James Newman. James dives into a memorable story from his days in the nuclear industry, where a seemingly simple task—replacing O-rings during a refueling outage—escalated into a high-stress situation. With incomplete briefings, unexpected challenges, and mounting pressure, James and his team had to think on their feet to avoid critical delays. This incident highlights the nuances of human performance under stress and the importance of clear communication, proper preparation, and systemic support. Throughout the conversation, we reflect on how assumptions, biases, and resource limitations shape workplace dynamics. We explore how leaders can create environments that encourage curiosity, transparency, and continuous learning to navigate complex challenges effectively. Whether you're a safety professional, leader, or curious listener, this episode offers insights into balancing operational efficiency with human-centered approaches. Recommended Resources: Think Again by Adam Grant The Right Kind of Wrong by Amy Edmondson Psychological Safety Playbook by Karolin Helbig and Minette Norman A Walk in the Woods by Bill Bryson Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

In this episode, I am joined by Becky Ray, founder of Culture Kick, to explore how context, culture, and unseen dynamics lead to decisions that might, on the surface, seem irrational. Becky shares a gripping story of a technician working under an unsupported load, leading to a devastating injury. Together we unpack how systemic pressures, missing processes, and organizational norms shaped the conditions that led to the event. We challenge the "should have, could have" judgments that dominate early narratives and highlight the importance of curiosity and non-judgmental inquiry in discovering actionable insights. If you’ve ever wondered how to move beyond blame and into real learning, this episode is packed with stories, insights, and practical takeaways for building safer, high-performing cultures. Tune in to hear how curiosity, empathy, and storytelling can transform the way we approach safety and leadership. Links: Visit Becky Ray’s website: www.culturekick.co.uk Recommended reading: Accident Report Interpretation by Derek Herigaty Book suggestion: Humble Inquiry by Edgar Schein Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

In this episode, I explore a striking story with Andy Barker, a strategic leader with decades of global experience. Together, they examine a workplace incident where quick judgments labelled an action as “stupid”—a worker losing fingers after grabbing a running machine belt. But as Andy reveals, the story is far more complex. He digs into organizational pressures, systemic failures, and cultural patterns that led to this moment. Instead of stopping at blame, they uncover insights about leadership accountability, competing priorities, and the need to align teams for safety and success. Listen to discover how leaders can move from blame to learning, ask better questions, and create environments where collaboration thrives and systemic risks are resolved. If you want actionable insights into leadership, workplace safety, and cultural improvement, this episode is for you. Resources Recommended: Andy Barker’s Website:  Gap in the game    Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

In this episode of How Did It Make Sense?, we explore the deeper story behind a scaffolder’s dismissal for violating fall protection rules near an active edge. While the surface narrative suggests a simple case of rule-breaking, the second story reveals a web of personal challenges, organizational dynamics, and overlooked systemic issues. My guest, David Wollage, a New View safety coach, shares his firsthand experience investigating the incident and reframing it as an opportunity for learning rather than blame. We delve into how stress, fatigue, and personal circumstances impact decision-making, the role of leadership in shaping safety culture, and why systemic issues like unreported scaffolding modifications create hidden risks Find David Here: New View Safety Coach - YouTube New View Safety Coaching | Organisational Coaching Perth | Perth WA, Australia Recommended Resources: The Coaching Habit by Michael Bungay Stanier: A guide to implementing coaching-led leadership. Coach the Person, Not the Problem by Marcia Reynolds: A deep dive into organizational coaching and its transformative potential. Find Gareth Here: Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

Today I am joined by Ben Cattaneo, founder of The Decision-Making Studio, to explore the fascinating world of decision-making under uncertainty. Ben shares a compelling first story about an organization entering the Chinese market, drawn by opportunity but ultimately facing challenges they didn’t foresee. It’s a classic case of a simple narrative—“they didn’t understand the market”—but as we unpack the second story, we explore the deeper factors at play: local rationality, fear of missing out, internal pressures, and incentive structures that drive decisions in complex systems. Find Ben Here: Website: The Decision-Making Studio LinkedIn: https://www.linkedin.com/in/ben-cattaneo/ My "FOCUS" decision-making framework: https://thedecisionmaking.studio/wp-content/uploads/2024/09/FOCUS.pdf Recommended Resources: Thinking in Bets by Annie Duke Quit: The Power of Knowing When to Walk Away by Annie Duke Gary Klein's Works on Intuition and Decision-Making Find Gareth here: Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

In this episode, I'm joined by Mike Mason, an experienced fast-jet pilot, flight instructor and The Human Diver trainer, to explore the often-overlooked complexity of human factors in high-risk environments. Mike brings a fascinating perspective, blending his experience in the Royal Air Force and his passion for diving, to shed light on how decisions are made under pressure. We dive into a reported incident involving an MQ-9 Reaper UAV crash and dissect the layers of context that often go unnoticed in simple “first stories.” Together, we discuss fatigue, local rationality, and the influence of organisational culture on decision-making in critical situations. What struck me in this conversation is how much we focus on blame rather than curiosity. Mike and I unpack the gaps in traditional incident reporting and the missed opportunities to learn, adapt, and grow. It’s a thought-provoking discussion on the messiness of real-world operations and why understanding the conditions that shape behaviour is key to improving outcomes. Whether you’re in aviation, diving, or any other high-consequence industry, this episode is packed with insights on how we can move beyond ticking boxes and start building a culture of genuine learning. Resources Mentioned: Book Recommendation: Field Guide to Understanding Human Error by Sidney Decker Mike Mason’s Website: On Target Teaming The Human Diver: Learn More Accident Report from USAF: https://www.afjag.af.mil/Portals/77/LinkClick.aspx?fileticket=rE1pY1KpuPw%3D&portalid=77 Research: What you look for is what you find - Lundberg et al.  What you find is not always what you fix - Lundberg at al. Connect With Us: Gareth: LinkedIn Mike Mason: LinkedIn Find me here: Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here

Today, I’m joined by Ben Goodhart, founder of Magpie Human Systems, a consultancy working in high-stakes industries like aviation, energy, and healthcare. Ben’s background as a pilot, accident investigator, and lifelong adventurer makes him uniquely qualified to dig into the nuances of risk and reward, and he does so with humor, insight, and honesty. In this episode, Ben shares some fantastic stories—from a near-disastrous glissade on a snowfield (while wearing crampons!) to a high-speed mountain bike crash that left him with a neck brace and a powerful reflection on risk. These stories are more than entertaining; they dive into the deeper questions of why we take risks, how we manage them, and what we learn when things don’t go as planned. We discuss the idea of risk not just as a negative concept but as a pathway to adventure, growth, and self-discovery. Ben brings fresh perspectives on the balance between control and surrender, the evolution of safety technology, and the ways adventure sports can teach humility, curiosity, and resilience. Along the way, we draw parallels to high-risk industries, exploring how decision-making under pressure and the negotiation of trade-offs applies to both work and play. Find Ben Here: Ben Goodhart’s consultancy: Magpie Human Systems Resources Mentioned: Minus 148 Degrees: The First Winter Ascent of Mount McKinley by Art Davidson Reinhold Messner’s mountaineering books Risk Savvy: How to Make Good Decisions by Gerd Gigerenzer Find me here: Human in the System  Transforming teams. Unlocking human potential. Using principles from Human Factors (HF), High-Reliability Organisations (HRO), and Human and Organisational Performance (HOP), we develop and deliver highly immersive and impactful programmes using the High-Velocity Learning LAB (HVLL) concept. We give you the know-how, the tools and the support to make results stick and empower your people to achieve the extraordinary. We help you answer the question "How do we uncover those hidden stories in our organisation?" Contact us here