Features
- Focus on system defenses and conditions, not blame
- Identify improvement actions and check effectiveness
- Share "how work happens" insights across teams
- Include those involved in the event in sense-making
- Publish learning memos quickly
02
Action Tracking & Effectiveness
Features
- Each action has an owner, due date, and verification step
- Automated reminders; ageing reviewed weekly
- Visible progress dashboards
- Sampling to verify actions are effective, not just closed
- Escalation for overdue/high-risk items
03
Trend & Review Huddles
Features
- Routine, cross-functional reviews of trends and weak signals
- Balance proactive indicators with reactive ones
- Trigger deeper dives when warning signals appear
- Assign experiments (PDSA) and review outcomes
- Document and spread successful adaptations
04
Rapid Resource Deployment for Safety Fixes
Features
- Pre-approved mechanisms to allocate time/money/experts fast
- Track time-to-resource and time-to-close
- Leaders unblock constraints promptly
- Employees can cite examples of quick support
- Monthly review of bottlenecks and improvements
05
MOC & Readiness Rigor Reviews
Features
- Secondary check of management of change for blind spots
- Hunt for "work-arounds" and normalize escalation
- Field verification before go-live; sign-off includes user reps
- Capture lessons for future changes
- Metrics on MOC quality and effectiveness over time
06
Investigation Tools & Methods
Features
- "5 Whys" for underlying causes
- Root-cause analysis using a valid tool
- Process to identify cultural threats
- Learning-team processes to capture learning opportunities
- Barrier analysis (e.g., Bowtie) of system failures
07
Team-Based Investigations
Features
- Team led by a safety professional including employees and managers
- Involves safety professionals and managers
- Involves employee representatives
- Involves colleagues of those involved
- Involves supervisors and, where needed, external experts
08
Investigation Results Sharing
Features
- Share with the management team
- Share at safety meetings
- Share with all employees (and those involved)
- Share with the regulator
- Share with industry peers / general public as appropriate