Counter Errorism
Counter-Errorism - Episode 28 - Todd Conklin
Episode Summary
In this episode of Counter Errorism, Todd Conklin shares key insights on creating a sustainable learning culture and improving operational performance: Leadership Transformation as the Priority: Real organizational change must begin with the leadership team because leaders act as the ultimate gatekeepers to safety and reliability culture. Unless leaders transform how they view their workplace, organizational progress cannot be sustained. Shift from "Worker as Problem" to "Worker as Solution": Organizations must stop viewing workers as the problem to be fixed and instead recognize them as the primary solution and source of operational knowledge. Separate Investigating from Fixing: The sole purpose of an investigation is to learn, describe how an event occurred, and establish "judgments of need". Program owners—rather than investigators—should own and design the corrective actions to prevent superficial fixes like adding signs or mandatory retraining. Lead with Curiosity Over Culpability: Moving away from rigid tools like culpability matrices, true learning organizations rely on psychological candor and relentless leadership curiosity about normal, everyday work.
Episode Notes
Get to know Todd Conklin
Profile: linkedin.com/in/todd-conklin-64b8a8a
Email: toddconklin@gmail.com
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:
1. Leadership Transformation is the Primary Lever
- 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.
2. Shift from "Worker as Problem" to "Worker as Solution"
- 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.
3. Separate Investigating from Fixing (Learning vs. Corrective Action)
- 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.
4. Focus on Extent of Condition Over "Cause"
- "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.
5. Replace Culpability Matrices with Curiosity and Candor
- 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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