This principle reminds us that humans are fallible and mistakes are an inevitable part of complex systems.
What is Error is Normal?
This first step ensures the topic is clear and the right people are invited—those closest to the work.
What is Prepare?
A good facilitator stays open-minded, non-judgmental, and curious. This word summarizes their approach to uncertainty.
What is humble?
Instead of asking “Did you follow the procedure?”, a better question is this one that explores what actually happens during daily work.
What is “What does normal work look like?”
These two lines represent the difference between “work as imagined” and “work as done.”
What are the Black Line and the Blue Line?
By recognizing recurring conditions and triggers, this principle empowers teams to prevent future missteps.
What is We Can Predict and Manage Error-Likely Situations?
During this session, the team explores how work is really done compared to how it’s expected to be done.
What is Session I: Learn?
Instead of trying to solve too early, a skilled facilitator uses this model to foster new insights.
What is protect Hierarch of Controls?
A Question such as this: “Where is it easy to make a mistake?” is called....
What is an open-ended question?
This critical visual tool used during Session I helps teams see the story together by organizing events, context, and contributing factors.
What is the Wall of Discovery (Comparative Timeline)?
This principle emphasizes that people's decisions often make sense based on their environment and systems.
What is Context Influences Behavior?
This intentional pause between sessions allows time for new insights to surface.
What is Soak Time?
These three traits—humble, curious, and this—help facilitators stay grounded and avoid acting like experts.
What is ignorant?
When practicing good questions you will have your first attempt in learning.
What is “FAIL?”
This model reminds facilitators to guide teams toward systemic solutions by starting with elimination and substitution, not just PPE.
What is the Hierarchy of Controls?
According to HOP, this common reaction halts learning and undermines safety culture.
What is Blame Fixes Nothing; Learning Yields Improvement?
In this phase, teams evaluate error traps, brainstorm solutions, and agree on what to improve first.
What is Session II: Brainstorm & Prioritize?
To maintain psychological safety, facilitators should set clear expectations and encourage this type of communication from participants.
What is honest and open communication?
A great way to encourage a conversation of learning.
What is “Tell me about what happened.”?
This principle helps teams sort solutions into three levels: what they can control, what they can influence, and what they’re concerned about.
What is the Sphere of Influence?
This principle reinforces that what leaders do after an event will shape whether people feel safe to speak up in the future.
What is Response Matters?
This final step involves documenting outcomes, testing improvements, and sharing learnings across the organization.
What is Take Action?
Great facilitators avoid yes/no or blame-seeking questions. Instead, they use this type of question to understand how work is really done.
What are open-ended questions?
This future-focused question helps teams identify hidden risks by imagining where the next incident could occur.
What is “Where/how will the next OSHA recordable (or SIF) occur at this site?”
According to Rob Fisher, this percentage of events are caused by factors beyond just the individual closest to the incident.
What is 90%?