PreAccident Investigation Podcast

This episode previews a small workshop in Santa Fe where Todd Conklin, Ann Lyren, and guest ReDonda Vaught will explore a tragic patient safety case. They frame accidents as the unexpected combination of normal performance variability and discuss how to learn from such incidents.

Listeners will hear about the meeting goals (March 31–April 1), opportunities to chart the event, and practical tactics for organizations to identify and ...

Todd Conklin explores why its so difficult to measure events that never happen and how traditional safety metrics can mislead organizations. He argues for focusing on metrics that validate safeguards and create desired outcomes rather than only counting accidents.

The episode also touches on automation risks, the limits of frequency-based measures, and the need for better leading indicators and verification practices to keep syste...

Todd Conklin opens 2026 reflecting on why how we begin interactions and jobs matters more than we often realize. He uses stories from travel, aviation, and workplace examples to show that the start of an encounter often predicts its outcome.

Conklin urges listeners to choose kindness, psychological safety, and deliberate planning—start the job when the right controls are in place—rather than beginning from hate, division, or aggre...

10. New Year’s Eve recap reflecting on a busy 2016 and the journey ahead into 2017.

9. Host shares personal travel highlights and experiments in gratitude and generosity.

8. Announces a 2017 focus on seeking and affirming the fundamental goodness in people.

7. Reviews safety’s evolution: from compliance (Safety One) to safety-by-design (process safety).

6. Explains the current phase emphasizing human performance and managing va...

This special Thanksgiving 2021 episode shares one simple piece of advice: be grateful. It highlights the power of gratitude during hard times and encourages you to pause and appreciate what you have.

When the world feels difficult, instead of meeting pain with pain, reflect on the people, support, and good things in your life. Gratitude helps you move forward with strength and perspective.

Learn something every day, have fun, and...

This episode shifts the safety conversation from continuous improvement to continuous capacity, introducing a practical dashboard of 10 operational indicators—five system capacities (exposure to unforgiving energy, robustness of safeguards, error tolerance/recoverability, detectability of variance, and recovery capacity) and five human capacities (sensitivity to variation, frontline insight, quality of learning, psychological safet...

Todd Conklin talks with Brent Sutton and Jeff Lyth about the upcoming HOP Workshop in Vancouver (Jan 28–29, 2026), centered on Redonda’s powerful firsthand story of patient safety, complex systems, restorative justice and resilience — lessons that translate across industries.

Day one features Redonda’s narrative and panel discussion; day two focuses on hands‑on learning and innovation. Please attend, this workshop will be amazingly...

This episode explores human performance and aviation safety, contrasting airline procedures with general aviation risks. Guests discuss building safety margins, the importance of planning vs. acting, and how economic pressures can erode resilience.

Highlights include treating near-misses as learning opportunities, practical tips for pilots to increase recoverability, and real-world examples from naval operations and long-term flyi...

Jay Allen interviews Todd Conklin about his new book, The Stability Trap, exploring why even safe, stable organizations can fail. They discuss the "drive to zero," complacency, pressures on middle management, wearables and data, and lessons from aviation and the pandemic.

The episode also covers how AI was used to reorganize the book’s ideas and help craft its ending, and offers practical reframes: treat safety as a capacity, see w...

Host Todd introduces his new book, The Stability Trap, and shares a sneak peek episode created with an AI-generated interview. The episode explores why organizations that appear safe can still experience accidents and how success itself can erode safety capacity.

The discussion outlines the core ideas: safety as the presence of capacity, the three R's (redefine safety, reframe the worker, relearn investigation), and a five-stage p...

In this episode Todd Conklin joins Jowanza Joseph to explore modern safety thinking: why human error is normal, how context shapes behavior, and why leadership response and system recoverability matter more than blame.

They draw on examples from Los Alamos, AWS outages, SpaceX and everyday technology to show how organizations can design systems that tolerate failure and learn from it.

Listeners will get practical insights into the ...

Todd Conklin joins the Brisbane Safety Differently Book Lab in Auckland for a lively discussion about leadership, accountability, and learning from everyday work. The group explores why safety is the presence of control, how leaders should respond after incidents, and why learning is the new currency of safety.

Todd shares stories about writing his books, engaging with workers, and practical steps leaders can take to build confide...

Part two of the RaDonda Vaught story examines what emerged after the event: investigation details, system design flaws, communication breakdowns, and the tiny timing error that mattered. RaDonda Vaught recounts how normalized overrides, software defaults, and organizational assumptions created conditions for failure.

The episode explores the chilling effects of criminalizing mistakes, the human cost across patients and providers, a...

In this episode, nurse RaDonda Vaught tells the detailed, context-rich story of a medication error at Vanderbilt that led to criminal charges. She walks through the events, system issues (including a recent EHR rollout and medication-dispensing delays), distractions, and decision points that contributed to the mistake.

RaDonda describes how workarounds, unclear documentation in radiology, drug supply changes, and interruptions comb...

Episode: an extended open Q&A from the Pre-Accident Investigation Conference in Santa Fe covering big-picture safety topics.

Speakers discuss the limits of traditional metrics, the power of real-time monitoring, shifting focus from managing risk to maintaining control, validating controls in the field, learning teams, contractor relationships, and prioritizing high-information events. Anecdotes and practical guidance illustrat...

Todd Conklin and Brent Sutton discuss the short-term future of safety thinking—covering the rise and fall of lean/TQM, how commodification can slow innovation, and why fear, FOMO and complacency shape which ideas stick. They explore leaders' responsibility, weak signals, and the need for small 'safe-to-fail' experiments to keep systems resilient.

Set in Santa Fe with lighthearted moments (including breakfast burritos and a cheese ...