PreAccident Investigation Podcast

In this episode Todd Conklin joins Jowanza Joseph to explore modern safety thinking: why human error is normal, how context shapes behavior, and why leadership response and system recoverability matter more than blame. They draw on examples from Los Alamos, AWS outages, SpaceX and everyday technology to show how organizations can design systems that tolerate failure and learn from it. Listeners will get practical insights into the five principles of human performance and how to build resilient systems that fail safely and recover quickly.

Todd Conklin, a renowned safety thinker and author, lights up discussions in Auckland about leadership and learning in the workplace. He emphasizes that safety is about the presence of control and explores how leaders' responses shape improvement. Todd argues that everyday learning should replace incident counting, highlights the importance of humility in leadership, and offers practical steps to foster a learning culture. He shares engaging stories from his writing journey, revealing how to build systems that gracefully handle failures.

Part two of the RaDonda Vaught story examines what emerged after the event: investigation details, system design flaws, communication breakdowns, and the tiny timing error that mattered. RaDonda Vaught recounts how normalized overrides, software defaults, and organizational assumptions created conditions for failure. The episode explores the chilling effects of criminalizing mistakes, the human cost across patients and providers, and the case for shifting from blame to system-focused learning and improvement.

RaDonda Vaught, a registered nurse at Vanderbilt, shares her harrowing experience of a medication error that led to criminal charges. She delves into systemic issues surrounding a new EHR rollout and urgent workarounds that contributed to the tragedy. RaDonda recounts the pressure of a time-sensitive request and how distractions at the dispensing cabinet led to a misadministration of a paralytic instead of the intended medication. This candid reflection highlights the complexity of healthcare systems and sparks critical conversations about patient safety.

Episode: an extended open Q&A from the Pre-Accident Investigation Conference in Santa Fe covering big-picture safety topics. Speakers discuss the limits of traditional metrics, the power of real-time monitoring, shifting focus from managing risk to maintaining control, validating controls in the field, learning teams, contractor relationships, and prioritizing high-information events. Anecdotes and practical guidance illustrate how organizations can learn without blame.

Todd Conklin explores how blame shuts down learning and prevents organizational improvement, arguing that blaming individuals creates a chilling effect that blocks thousands of future learning opportunities. He connects blame to misunderstandings about human error, emphasizes psychological safety, and urges leaders to ask "what failed" before asking "who failed," while sharing personal anecdotes and reflections.

Brent Sutton, a safety and organizational resilience expert, joins Todd Conklin to explore the future of safety thinking. They discuss the decline of lean and TQM, how commodification stifles innovation, and the vital role of weak signals in fostering resilience. The conversation takes a lighthearted turn with breakfast burritos and debates over cheese, but the core message emphasizes the need for small, 'safe-to-fail' experiments and leaders' responsibility to navigate workplace complexities. Staying curious about evolving safety practices is key to preventing stagnation.

Recorded live at Meow Wolf in Santa Fe, this episode features a wide-ranging conversation between Todd and Andy Baker about learning, safety culture, and leadership influence. They dig into HOP and related safety approaches, debate top-down versus middle-out change, discuss the importance of language and unlearning, and explore how to turn belief into practical skill and behavior. The episode offers real-world insights on piloting change, engaging leaders and middle managers, and learning from others who have adapted these ideas in novel ways.

Tiny Todd Conklin joins the No Way Out podcast to explore Human and Organizational Performance (HOP), high-reliability organizing, and how safety emerges from complex systems rather than individual mistakes. They critique traditional investigations, surveys, and risk matrices, and discuss practical ideas for building capacity, worker agency, psychological safety, and resilient operations.

The discussion tackles the alarming issue of children left in hot cars, emphasizing that such failures are often unintentional. It encourages a cultural shift towards understanding and implementing preventative measures, like technology and visual reminders. Strategies to foster safety awareness replace blame, prioritizing system-level changes. Additionally, there's a look at generational differences in workplace ghosting and the evolving challenges employers face in hiring, spotlighting the need for mutual understanding in the workplace dynamics.