2025 Community of Human and Organizational Learning 31st Annual Conference

Accidents in both software systems and industrial operations rarely stem from a single cause or individual action. They emerge from complex interactions, evolving pressures, and adaptive responses by people doing their best under uncertainty. We will explore how a non-blaming approach to incident investigation—rooted in resilience engineering and honed in high-velocity software environments—can offer powerful insights for improving safety in industrial settings as well. As a group, we will explore useful frameworks for conducting post-incident reviews that focus on understanding how work actually happens, rather than assigning fault. We’ll examine real-world examples that highlight the gap between assumptions and operational reality and discuss methods to uncover adaptive capacities that often go unnoticed.
We’ll challenge the assumption that eliminating human error is the path to safety, and instead offer practical strategies for supporting the people at the sharp end. Whether you’re maintaining a codebase or a refinery, the goal is the same: to learn, adapt, and build systems that can handle the unexpected. Attendees will leave with actionable strategies for fostering a culture of learning, improving systemic understanding, and building more resilient systems—without resorting to blame.