2025 Community of Human and Organizational Learning 31st Annual Conference

When intelligently designed and deployed this effort will positively impact the complexity around serious injuries and fatalities.   By leveraging Enterprise Safety and Health Software that is built on the Human and Organizational Performance (HOP) principles, allows organizations a more detailed modeling approach to identify groups of individuals, processes, or conditions that may create an unsafe event or SIF accident.  In the absence of having software solutions that incorporate HOP Principles, safety professionals are often forced to conduct concurrent manual processes that take away precious capacity to apply the right resources as the right time to prevent SIFs.

Up until now, we know that the basis of most safety data to date has been lagging based on historical incidents and observed data. The very nature of how traditional software solutions have been organized focus heavily on prevention and truly little on recoverability and resilience. This creates significant challenges for organizations to evolve their SIF prevention process and align the organization on the principles that matter most.

This session will walk through how one organization is applying software differently to achieve better insights and better results. The software improvements that will be shared are based on the presenters’ experience regarding operationalizing HOP in numerous organizations they support and a longer history working with traditional software applications. What this story will tell attendees is how software supports better leader observations and their discussions in keeping the conversation of risk alive, how controls are measured to understand if you are “lucky” versus “good” and how event reviews are supported to shift the focus away from fixing “who” versus “what.”

Course Description for APP: (50 words)

Armed with the insight from safety data captured with these software changes organizations can now focus limited resources on the things where the greatest return can be maximized, i.e., preventing workplace serious injuries and fatalities. Setting the right performance metrics ensure the right information is delivered to the right level at the right time so leaders can act.
Relevance:

Safety and health performance is traditionally measured by lagging indicators that rely on injury and illness statistics. Unlike processes such as production, safety is consistently measured by failure instead of accomplishment. A proactive approach—utilizing enterprise safety and health software designed with Human and Organizational Performance as its foundations focuses on tracking safety and health performance on the things that can cause and prevents serious injuries and fatalities.

Objectives:
1.    How leader observations focused on three simple questions captured through software can be harnessed to address the most significant risks for an organization.
2.    Efficiently capture and report how controls contributed to or prevented the SIF or SIF Potential to identify weaknesses and reinforce for leaders are we "lucky" or are we "good".
3. Align HOP language to support event reviews that focus on fixing "what" versus "who"

Join Ben Goodheart, Ron Gantt, and Dave Provan on an adventure through some of the BS that permeates the world of safety. Whether it’s platitudes, half-truths, or fiction, Ron and Ben will look at a few common safety practices with a focus on stripping away noise and doing what works for the folks doing the work. By choosing a few key topics with the audience, we’ll share stories and experiences to provide practical ways to keep safety human-centered, effective, and fun.

Tesla’s mission is to accelerate the world’s transition to sustainable energy. At Tesla EHSS we are laser focused on integrating HOP mindset into everything we do. HOP helps us ensure safeguards are based on the blue line. We are building our own Tesla EHSS data management system and HOP mindset is embedded into the system from Design to Reporting. MyEHS is our one stop shop for all EHSS activities. It integrates all EHSS information into one Tesla system. System deployment also enabled HOP aligned language in how we manage events.
For event learning, we have two approaches. SAFE Tool (Safeguard Analysis for Events) and Learning Teams. SAFE tool is simple with three questions 1. What safeguards existed and worked? 2) What safeguards existed and did not work? 3. What safeguards did not exist but could have worked). Learning teams are conducted on events as well as successful work. Environmental Social Governance is moving companies to report non-financial indicators on the 10k. For our lagging indicators, we are moving away from OSHA lagging indicators as lagging metrics and moving towards ASTM as the global metric for safety success. This allows us to focus on what is important rather than focusing on everything.
For our leading indicators, we have our Take Charge program. Take Charge program promotes a culture of improvement by empowering those closest to the work. Take Charge is used in 44 countries, 1616 locations, in 16 different languages. By January 2024, we had 1,136,000+ Take Charge submissions globally with more than 70,100 unique submitters.
We continue to track the traditional lagging indicators only within EHSS. However, we do not set targets for them, we do not include them on our executive dashboards, and we do not include them in our external reporting. They are for tracking/trending purposes and internal EHSS use only. Our focus tells the world what we prioritize.
As a key takeaway, we recommend the following: 1) Hire people that have HOP mindset so that systems, and processes naturally align as you move in your journey. 2) Focus on building capacity to fail safely over preventing all events. 3) Don’t set goals against lagging metrics. 4) Implement tools that enable learning from those closest to the work.

Introduction: In an era where safety and culture within organizations are paramount, traditional methods of engagement and education often fall short of making a lasting impact. This keynote presentation explores an innovative approach: utilizing stand-up comedy techniques to foster a culture of safety and enhance organizational culture.

Objectives and Scope: The presentation aims to demonstrate how storytelling, humor, and engagement techniques derived from stand-up comedy can create meaningful 'Aha' moments, fostering an environment where safety and culture thrive together. By dissecting elements such as the rule of three, audience engagement, callbacks, analogies, metaphors, and self-deprecating humor, we will delve into how these strategies can be effectively applied in non-comedic contexts to influence behavior and attitudes positively.

Main Arguments or Findings: Through a series of examples and case studies, we will uncover how humor can be a powerful tool for good, enabling everyone to find their unique comedic voice to create connections and act as influencers within their organizations. The presentation highlights the intrinsic link between truth and humor, showcasing how finding humor in everyday situations can enhance communication, creativity, and human connection.

Implications or Contributions: The implications of adopting stand-up comedy techniques extend beyond mere entertainment, serving as a catalyst for cultural transformation within organizations. This approach not only improves safety awareness and practices but also contributes to a more engaged, cohesive, and resilient workforce. By embracing humor as an essential element of communication, leaders and employees alike can foster a more inclusive and positive organizational culture.

Conclusion: Stand-up comedy offers more than just laughs; it provides a unique lens through which we can enhance safety culture and organizational engagement. By learning to wield humor effectively, we can create a workplace where safety is integrated seamlessly into the culture, and every individual feels valued and connected.
I can be contacted on +61 410 746 786 in Australia

The pandemic has led to an increased resonance surrounding psychosocial risk, highlighting its amplified relevance and prompting greater attention from various stakeholders. We now have international standards on this risk, and safety regulators worldwide are producing guidance and/or regulations to hold organizations accountable.
Brent Sutton and Diane Ah-Chan will present how the HOP Principles are being applied to understand this risk better, how designing better work creates better outcomes, and the role of “human error” and “system conditions” in psychosocial risk events from harassment and bullying to aggression and violence.

Background: 
Prior to 2022, United Airlines, the world’s largest airline by “available seat miles” (ASM), had a self-described “disconnected” approach to root cause analysis and organizational learning. Therefore, in 2022 United set out to identify a vendor to supply them with root cause analysis training, software, and support – primarily focused on Safety and Regulatory Compliance.  After an exhaustive search, they chose Sologic.

The scope of the program was broad.  All Safety incidents and risks would be reviewed using Sologic and Causelink.  Sologic would train the initial round of employees at multiple levels and then train a group of United “certified instructors” to take over from there.  All reportable regulatory issue reviews would also be conducted and reported using Sologic.

Why Applicable to CHOL:
In United’s case, they have truly embraced the learning journey.  They have created a learning “context” that maximizes uptake.  Their leadership, from VP level down, has shown that “how they respond matters.”  This presentation provides a very special and exclusive look “under the hood” of how these kinds of programs gestate, evolve, operate, and improve.

Perhaps most importantly, United is seeing results.  They now have a unified, consistent approach and toolset.  They are getting good uptake and buy-in.  And the regulator has been “extremely supportive” and “energized”.

The story of this journey is both widely applicable and should be interesting to CHOL attendees.  Companies can learn from what worked well for United – as well as what they might do differently next time.  Sologic can share what it’s like from the service provider’s perspective – as well as what we might do differently in the future.

"What created such a resilient response to the Mandalay Bay shooting?
Dr David MacIntyre will share with us his first-hand perspective as the trauma surgeon on call that night at Sunrise Hospital."

We learn through stories. Social/work groups share stories that inform group members how to stay socially safe from harm from other groups, what you can and cannot say to other groups, what motivates “other” groups, and who you can trust with information.
Not all stories are true! If someone trusted in a social group tells the group a story, it becomes the truth and becomes how groups sustain “truths that aren’t true”. Stories like “employees are our problem”, “the reason we have problems is that employees don’t engage”.
We often see data that validates our assumptions of what is true if we don’t have a way to challenge those assumptions.
In this presentation, the speaker provides 3 steps to understanding engagement through listening and narrative analysis, understanding how to influence group stories to align diverse groups around organisational purpose, and how to tell true stories that build momentum towards a desired future.
Short Description:
Changing the business narrative: Understanding how to
1.    Deconstruct the stories people share to reveal perceived truths, reasons for engagement;
2.    How to build a strategy to positively influence the narrative, &
3. How to build momentum by telling success stories that deliver the future you want to be part of.

MRI celebrates its reputation as 'the safe imaging option,' sometimes to its own detriment. In 2023, a hospital in a prominent healthcare organization experienced a catastrophic, near-fatal MRI accident, which almost evaded regulatory review. Thanks to public investigation records from both CMS and OSHA, a more comprehensive Root Cause Analysis could be done, illuminating failures in management & oversight, ambiguous lines of authority and responsibility, poor training, and normalization of deviance from safety practices. The analysis also suggests a hospital so wrapped up in its patient safety scores and confirmation-seeking that failed to identify longstanding weaknesses in their MRI safety.

This session identifies the specifics of what happened, highlighting the direct and indirect actions of each party, recreating the accident, including scaled representations of the MRI suite and animations of the events, pulled from the official accounts.

Then the presenters will share their RCA of the event, which breaks down the day’s activities to reveal latent, underlying causes and contributing factors, identifying the contributions of faulty training, failures of competency verification, lapses in oversight, and dangerous presumptions that regulatory or accreditation structures provided some assurances of MRI safety at the hospital.

Lastly, the presenters will share a series of identified remedial steps, applying to individuals, the hospital organization, and to the regulatory and oversight structures designed to provide assurances of minimum quality and safety. Without a complete feedback loop that breaks through the ‘safe imaging option’ bumper-sticker slogan and creates change, more accidents like this will happen in the future.

We presented “ChatGPT: the Good, the Bad, the Ugly” in last year’s conference.  This session will provide a one-year update to that presentation. This includes conducting the survey on the awareness and use of Generative AI technologies that was done in last year’s session, to see how the numbers have changed in this rapidly evolving area.
New to this year’s session will be a moderator-led panel discussion among experts and advisors familiar with these technologies.  The panel will then open up to the audience for an interactive discussion and sharing of experiences.

The Learning and Improvement Team (LIT), developed in partnership between American Airlines (AA) and the Allied Pilots Association (APA), is a blossoming safety program designed to learn what makes flight operations successful. Aviation safety has traditionally focused on accidents and unwanted outcomes but as the industry has become much safer those events have become fewer and far between, thus providing fewer opportunities to learn. LIT is designed to capture data on what goes well and why in AA flight operations. Because the Learning and Improvement Team uses relatively new safety science approaches including Safety-II and Safety Differently, it has faced some challenges in its development and implementation. Awareness of the program and a general understanding of its capabilities have been slow to develop but are greatly improving. Additionally, data analysis and presentation have proved challenging because the data collected looks unconventional when compared to existing data sources. Despite these challenges, the program has steadily expanded and found a place of permanence within the airline’s Safety Management System (SMS). By LIT facilitating the ability to look at all operations, not just the negative outcomes, American Airlines and its pilots can be better positioned to learn, both as individuals and as an organization.

What do Wildland Fire Fighters and Software Engineers have in common?
They’ve both taken the position that the most important thing after an incident is LEARNING. What may be shocking to some, is they both believe that the learning they produce is more important than corrective actions. In fact, corrective actions are not required – or even desired – for some incidents.
In this session, leaders from both communities will share how they learn from incidents. They will explore commonalities in their practices, what is most important for learning, and what they do differently and why.
“We love incidents. Well, love is a strong word. But incidents don't have to be a terrible experience. The community we started has spent a lot of time understanding just how much value you can get out of incidents, and how they can be used as a way to disseminate expertise throughout the organization.” Learning From Incidents Community of Practice (Software)

• Persephone Whelan led the team that recently revised Wildland fire Learning from Unexpected Outcomes and Learning Review process.
• Joe Harris has spent the last two years as the chair of the Response Protocol steering committee which is in charge of training and implementation of the accident review processes within the wildland fire community.
• Thai Wood is part of the Software Learning from Incidents Community of Practice.

We’ve come a long way since the pioneer days of Human Performance. All along the way, we’ve used systems learning, powered by systems thinking, to forge better approaches to making complex things work. Today, we will explore how we can unpack some of this collective ‘tacit’ knowledge about our systems to reduce the number of shiny objects on the safety net we maintain for our expert workforce, making it less distracting and stronger. This presentation will explore the systems, systems thinking, and systems learning that sit outside of Jens Rassmussen’s Dynamic Safety Model, functionally turning it into a Dynamic Operations Model.

Key concepts
•    Collective mental models (static) enabling collective mental pictures (dynamic)
•    How Organizations help to reduce the gradients in Rasmussen’s model
•    Understanding how we are succeeding – deep technical understanding
•    Hidden feedback loops - conversations
•    Loosening the reins – designing imperfect systems, on purpose
•    Thinking like an operator – staying light on our feet
•    Expert intuition
•    Supporting experts – weaving and maintaining the safety net
•    Influencing leaders – implementing strategies for servant leadership

Accountability is the foundation of the relationship between a leader, the team and individual team members. Creating accountability is fundamental and ongoing leadership practice. To hold someone accountable after a failure is to reexamine the accountability relationship and perhaps restructure it. That blame, an ego-defense to fear, anger, or shame, has been equated with accountability is simply evidence of a failure of leadership in organizations. This talk will address what effective accountability looks like and how to create it. It will also discuss why blame arises, from a psychological perspective, and how to manage it. The goal of the talk is to help you go back to your organization and break up accountability and blame for good.

We have choices:
Blame and Punish
Learn and Improve

• The Worker is NOT the problem to be fixed.  The Worker is the problem solver.
• We make our organizations safer by making our systems more robust and resilient.
• Therefore, We try not to tell our workers what to do - We ask workers what they need to manage safe work.
• We Define Safety as the Presence of capacity.