Paradigm Check Point: Prefacing Debriefings

I’m a firm believer in restating values, goals, and perspectives at the beginning of every group debriefing (e.g. “postmortem meetings”) in order to bring new folks up to speed on how we view the process and what the purpose of the debriefing is.

When I came upon a similar baselining dialogue from another domain, I thought I’d share…

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  • Risk is in everything we do. Short of never doing anything, there is no way to avoid all risk or ever to be 100% safe.
  • How employees (at any level) perceive, anticipate, interpret, and react to risk is systematically connected to conditions associated with the design, systems, features, and culture of the workplace.
  • “Risk does not exist “out there,” independent of our minds and culture, waiting to be measured. Human beings have invented the concept of “risk” to help them understand and cope with the dangers and the uncertainties of life. Although these dangers are real, there is no such thing as a “real risk” or “objective risk.””*
  • The best definition of “safety” is: the reasonableness of risk. It is a feeling. It is not an absolute. It is personal and contextual and will vary between people even within identical situations.
  • While safety is an essential business practice, our agency does not exist to be safe or to protect our employees. We exist to accomplish a mission as efficiently as possible–knowing that many activities we choose to perform are inherently hazardous (for example, deployment, data migration, code commits, on-call response, editing configurations, and even powering on a device on the network).
  • Mistakes, errors, and lapses are normal and inevitable human behaviors. So are optimism and fatalism. So are taking shortcuts to save time and effort. So are under- and over-estimating risk. In spite of this, our work systems are generally designed for the optimal worker, not the normal one.
  • Essentially every risk mitigation (every safety precaution) carries some level of “cost” to production or compromise to efficiency. One of the most obvious is the cost of training. Employees at all levels (administrators, safety advisors, system designers, and front-line employees) are continuously–and often subconsciously– estimating, balancing, optimizing, managing, and accepting these subtle and nuanced tradeoffs between safety and production.
  • All successful systems, organizations, and individuals will trend toward efficiency over thoroughness (production over protection) over time until something happens (usually an accident or a close call) that changes their perception of risk. This creativity and drive for efficiency is what makes people, businesses and agencies successful.
  • Our natural intuition (our common sense) is to let outcomes draw the line between success and failure and to base safety programs on outcomes. This is shortsighted and eventually dangerous. Using the science of risk management is more potent and robust. Importantly, Risk Management is wholly concerned with managing risks, not outcomes. Risk management is counterintuitive.
  • Employees directly involved in the event did not expect that the accident was going to happen. They expected a positive outcome. If this is not the case, then you’re not dealing with an accident.

*Paul Slovic, as quoted in Daniel Kahneman, Thinking Fast and Slow (Farrar, Straus and Giroux, 2011), p141.
The above is excerpted from the Facilitated Learning Analysis Implementation Guide, US Forestry Service, Wildland Fire Operations.


  1. Mark Tomlinson   •  

    Ya know John, every time that I hear someone tapping the “innovation craze” in the tech industry and they say “No one’s every done this before!” – I never believe it.

    Thanks to the US Forestry Service we might have all the concepts we need to operate safely and successfully in the IT domain.

    Cheers and thanks,


  2. JW   •  

    As a new person stumbling upon this page, I wonder what, the acronym, FLA means?

  3. Pingback: SRE Weekly Issue #35 – SRE WEEKLY

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