2025 Community of Human and Organizational Learning 31st Annual Conference

This workshop introduces a practical investigation approach that shifts from a traditional recurrence-prevention mindset to a learning and systemic risk-reduction model. This methodology aligns with High-Reliability Organization (HRO) principles, ensuring investigations drive meaningful improvements.
1. Preoccupation with Failure: Seeking Weak Signals
HROs look for weak signals before they escalate into major incidents. Conventional investigations focus on the immediate event, missing underlying system vulnerabilities.
• Investigations should capture and analyse near misses, deviations, and adaptive behaviours to uncover systemic weaknesses before failures occur.
• Analysis should integrate social and physical sciences to better understand risk and systemic contributors.
2. Reluctance to Simplify: Understanding Systemic Complexity
HROs acknowledge that a single factor rarely causes failure. Investigations must resist oversimplified cause-effect relationships and analyse how multiple systemic factors interact.
• Investigators should assess the organisational context, management systems, resource constraints, and operational realities that shape worker decisions.
• Understanding the interdependencies within an organisation leads to more effective risk-mitigation strategies.
3. Sensitivity to Operations: Learning from the Reality of Work
Safety is dynamic, and work is rarely performed exactly as procedures dictate. Investigations should reveal the gap between “work as imagined” and “work as done.”
• Discovering daily work practices and frontline adaptations provides a richer understanding of operational risk.
• Organizations must develop resilient and flexible systems that account for the variability in real-world work environments.
4. Commitment to Resilience: Designing Risk-Reducing Recommendations
Many recommendations rely on retraining and discipline, which do not reduce systemic risk. HROs build resilience by designing risk controls that are practical, measurable, and effective.
• Investigators should prioritise engineering and system-based controls over administrative solutions to create more robust defences.
• Effective recommendations should address underlying system vulnerabilities and enhance an organisation’s ability to absorb disruptions.
5. Deference to Expertise: Valuing Frontline Insights
HROs empower those closest to the work to inform decisions. Investigations must actively engage workers to understand how they navigate risks in real-time.
• Investigators should co-develop solutions with frontline workers, ensuring recommendations are both practical and impactful.
• Encouraging open reporting and engagement fosters a culture of trust and continuous learning.
6. Transforming Investigation Reports: From Historical Records to Business Cases
Investigation reports often focus on what happened but must evolve into tools that drive meaningful change.
• Reports should present findings as business cases, demonstrating the cost-benefit of systemic improvements.
• Recommendations should include justifications for risk-reduction strategies backed by data and system insights.
This workshop provides the tools to transform workplace investigations into drivers of lasting risk reduction.