Human in the System


podcast now live!

 

 

 

Available across all syndicated platforms including Spotify and Apple Podcasts

'How did it make sense?' explores the local rationality of those involved in doing what they did. Each podcast lasts about 45 minutes and aims to follow a similar format. Initially, we will look at the 'first story' of the event which is normally scant in details and triggers an emotional response, and then we will look at the 'second story' that looks at the goal conflicts, the ambiguities, the assumptions, the tensions, and the trade-offs that led to those involved doing what they did. This context-rich story is the one that learning opportunities come from, not focusing on the counterfactuals that often arise from 'first stories'.  

 

Ep. 24: Marcus Dimbleby and Gareth Lock

What happens when someone tests your emergency plan—and no one’s ready? In this episode of How Did It Make Sense?, I speak with Marcus Dimbleby, ex-RAF Wing Commander and now partner at Effective Direction, about the moment he walked into an ops room and triggered the crash alarm on purpose.We unpack how critical thinking, red teaming, and stress testing systems reveal the hidden flaws in safety procedures, leadership cultures, and team behaviours. It’s a story that moves from chaos to commendation, with lessons every business leader and risk manager should hear.

 
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Ep. 23: Chris Davies and Gareth Lock

Chris shares a story from his military aviation days – a high-pressure scenario involving rapid descents, rotor overspeed’s, and a well-intended but misguided fine imposed by leadership. It’s a classic example of where human error meets systemic misunderstanding. We unpack the layers of this case: What happens when leaders focus on punishment instead of understanding? Why do we so often recognise the frontline worker’s rationality but fail to apply the same empathy upwards? And what are the risks when oversights at the top are dismissed as incompetence rather than pressure-driven decision-making? We also explore how this kind of thinking shows up across industries – from healthcare to aviation, defence to energy. It’s not just about individuals; it’s about the systems they operate in, and the stories those systems tell.

 
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Ep. 22: Aaron Potash and Gareth Lock

In this episode of How Did It Make Sense?, I speak with Aaron Potash about a tragic diving incident in Monterey. A struggling student, a distressed instructor, and a beach full of bystanders—why did no one step in? This story raises important questions about how we recognise and respond to distress in high-risk environments. We explore the bystander effect, training gaps, and Immersion Pulmonary Edema (IPE), a little-known but potentially fatal condition that may have played a role. Despite its increasing recognition in the diving and medical communities, awareness and early detection remain limited. Aaron shares how this experience reshaped his approach to diver readiness and risk management, emphasizing the need for better training, clearer distress signals, and stronger safety cultures.

 
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Ep.21: Natia Ellis, Liam Duggan and Gareth Lock

In today’s episode of How Did It Make Sense? I sit down with two fellow Lund University graduates, Liam Duggan and Natia Ellis, to dig into the realities of police use of force and the critical role of second-story analysis. We start by dissecting a high-stakes policing scenario—a mental health crisis escalating to a fatal police shooting. The media-driven first story often simplifies these events, focusing on blame and hindsight bias. But what happens when we step back and consider the second story? Liam and Natia take us through their research, exploring the hidden systemic pressures shaping officer decisions—from policy constraints and training gaps to budget cuts and crisis response limitations.

 
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Ep.20: Ken Mudd and Gareth Lock

In this episode of How Did It Make Sense?, I am joined by Ken Mudd, a seasoned health and safety expert with over 25 years of experience across multiple industries. Together, they unravel the complex reality behind what seemed like a simple workplace accident—a contractor cutting into a live 415-volt cable, suffering burns in the process. But as we dig deeper, we uncover a story that started months before the actual event. From conflicting business goals, delayed shutdowns, and assumptions about safety protocols, to communication breakdowns and systemic weaknesses in contractor management, this case is a classic example of how “accidents” don’t happen in isolation. What lessons can we take from this incident to prevent similar mistakes? How do risk, business decisions, and safety intersect? And most importantly—what critical controls should have been in place?

 
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Ep.19: Kristian Gould and Gareth Lock

A state-of-the-art Navy frigate collides with an oil tanker in clear conditions—so how could no one on board see it coming? In this episode of How Did It Make Sense?, I sit down with human factors expert Kristian Gould to unpack the second story behind the high-profile 2018 collision of the Norwegian frigate Helge Ingstad. While the media fixated on blame and human error, Kristian reveals how this incident was anything but a simple mistake. We explore how background lighting, crew experience, shift handovers, communication breakdowns, and even systemic pressures in the Navy created the conditions for disaster. This conversation goes beyond the headlines to challenge the way we think about safety, accountability, and how organisations learn—or fail to learn—from high-consequence events.

 
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Ep.18: Jessie Singer and Gareth Lock

In this episode of How Did It Make Sense?, I sit down with investigative journalist and author Jessie Singer to challenge the way we think about accidents. Inspired by her book There Are No Accidents. Jessie shares the story of her best friend’s death, a so-called accident that, years later, played out in near-identical fashion with devastating results. But was it really just down to bad luck and poor choices, or was something bigger at play? We explore the uncomfortable truth about how blame obscures the real causes of harm, from road safety to workplace incidents. We unpack how narratives of individual failure let flawed systems off the hook, and why real change only happens when we stop treating accidents as inevitable. Whether you're in safety, leadership, or just want to see the world differently, this is an episode that will change the way you think about risk, responsibility, and the structures that shape our lives.

 
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Ep.17: Eoin Walker and Gareth Lock

When your airway kit gets vomited on mid-procedure, things get a whole lot harder—especially in a high-stakes, high-pressure medical emergency. In today’s episode on How Did It Make Sense, I’m joined by Eoin Walker from the World Extreme Medicine Forum, and we’re diving into one of the toughest cases of his career—a failed airway intervention that turned into an emergency tracheotomy. The patient was critically burned, time was running out, and just as they were about to secure the airway, the kit got covered in vomit. In the moment, everything was chaotic—30 people watching, critical decisions being made in seconds, and an overwhelming pressure to perform. This is the kind of case that looks straightforward in hindsight, but in reality, was anything but. 

 
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Ep.16: Ann Stow and Gareth Lock

When a big organisation acquires a small, thriving SME, it should be a perfect match—right? Not always.In this week's episode of How Did it Make Sense, I sit down with Ann Stow, Chartered Psychologist and founder of Humanise Work, to unpack the real story behind a merger that went wrong. Within months, key leaders had resigned, culture had collapsed, and trust was shattered. But what really drove those decisions? Ann breaks down the hidden pressures, communication failures, and cultural clashes that often go unnoticed but make or break business transformations. We explore why two-thirds of mergers fail, the cost of rushed decisions, and the lessons leaders need to learn before it’s too late. From understanding local rationality to the power of clear communication, this conversation is packed with insights for anyone navigating organisational change. If you want to keep good people, build trust, and avoid repeating the same mistakes, this one’s for you. Tune in and let’s get into the second story.

 
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Ep.15: Stephen Harvey and Gareth Lock

"If only they'd followed the rules"—a phrase we hear all too often in health and safety. But what if the story isn't that simple? In this episode of How Did It Make Sense?, I chat with safety expert Stephen Harvey to uncover the second story—the deeper, more complex reality behind incidents. Stephen shares his journey from mechanic to safety advocate after a near-fatal workplace accident and reflects on a tragic mining fatality where a worker’s decision-making was shaped by experience, pressures, and the realities of the job—not just disregard for rules. We also tackle the myth of stop-work authority, why humour is a powerful safety tool, and how real change comes from leaders who listen, not just enforce.

 
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Ep.14: Colette Alexander and Gareth Lock

In this episode I speak with Colette Alexander, Director of Site Reliability Engineering at HashiCorp, about software failures, risk in software testing, and resilience in engineering. We dive deep into the CrowdStrike outage, exploring why skipping tests in software releases can have catastrophic effects. But it’s not just about a software company making a bad call—it's about the trade-off between speed and safety, how software engineers balance risk, and why testing everything isn’t always an option. Colette shares insights from the world of site reliability engineering (SRE), drawing parallels with aviation, space disasters like Challenger, and even the psychology of teamwork in rock bands. This episode is a must-listen for anyone in software development, DevOps, cybersecurity, or engineering leadership who wants to understand the real-world impact of software testing decisions.

 
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Ep.13: Chad Todd and Gareth Lock

Today I am joined by Chad Todd a seasoned SRE Manager at CrowdStrike with over 20 years of experience in the tech industry. Chad shares with us a a detailed account of a recent system incident, breaking it into the first story—what happened at the surface—and the second story, which uncovers the deeper, systemic factors and decision-making processes involved. The conversation highlights the challenges of maintaining complex IT systems, the value of fostering a culture of learning from incidents, and the role of teamwork in troubleshooting under pressure. They discuss the importance of database maintenance, how latent conditions contribute to failures, and the art of adaptive problem-solving.

 
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Ep.12: James Newman and Gareth Lock

In this episode, I chat to Human Organizational Performance Manager James Newman. James dives into a memorable story from his days in the nuclear industry, where a seemingly simple task—replacing O-rings during a refueling outage—escalated into a high-stress situation. With incomplete briefings, unexpected challenges, and mounting pressure, James and his team had to think on their feet to avoid critical delays. This incident highlights the nuances of human performance under stress and the importance of clear communication, proper preparation, and systemic support. Throughout the conversation, we reflect on how assumptions, biases, and resource limitations shape workplace dynamics. 

 
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Ep.11: Becky Ray and Gareth Lock

In this episode, I am joined by Becky Ray, founder of Culture Kick, to explore how context, culture, and unseen dynamics lead to decisions that might, on the surface, seem irrational. Becky shares a gripping story of a technician working under an unsupported load, leading to a devastating injury. Together we unpack how systemic pressures, missing processes, and organizational norms shaped the conditions that led to the event. We challenge the "should have, could have" judgments that dominate early narratives and highlight the importance of curiosity and non-judgmental inquiry in discovering actionable insights. If you’ve ever wondered how to move beyond blame and into real learning, this episode is packed with stories, insights, and practical takeaways for building safer, high-performing cultures.

 
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Ep.10: Andy Barker and Gareth Lock

In this episode, I explore a striking story with Andy Barker, a strategic leader with decades of global experience. Together, they examine a workplace incident where quick judgments labelled an action as “stupid”—a worker losing fingers after grabbing a running machine belt. But as Andy reveals, the story is far more complex. He digs into organizational pressures, systemic failures, and cultural patterns that led to this moment. Instead of stopping at blame, they uncover insights about leadership accountability, competing priorities, and the need to align teams for safety and success. Listen to discover how leaders can move from blame to learning, ask better questions, and create environments where collaboration thrives and systemic risks are resolved. If you want actionable insights into leadership, workplace safety, and cultural improvement, this episode is for you.

 
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Ep. 9: David Wollage and Gareth Lock

In this episode of How Did It Make Sense?, we explore the deeper story behind a scaffolder’s dismissal for violating fall protection rules near an active edge. While the surface narrative suggests a simple case of rule-breaking, the second story reveals a web of personal challenges, organizational dynamics, and overlooked systemic issues. My guest, David Wollage, the 'New View safety coach', shares his firsthand experience investigating the incident and reframing it as an opportunity for learning rather than blame. We delve into how stress, fatigue, and personal circumstances impact decision-making, the role of leadership in shaping safety culture, and why systemic issues like unreported scaffolding modifications create hidden risks

 
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Ep. 8: Ben Cattaneo and Gareth Lock

Today I am joined by Ben Cattaneo, founder of The Decision-Making Studio, to explore the fascinating world of decision-making under uncertainty. Ben shares a compelling first story about an organization entering the Chinese market, drawn by opportunity but ultimately facing challenges they didn’t foresee. It’s a classic case of a simple narrative—“they didn’t understand the market”—but as we unpack the second story, we explore the deeper factors at play: local rationality, fear of missing out, internal pressures, and incentive structures that drive decisions in complex systems.

 
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Ep. 7: Mike Mason and Gareth Lock

I’m joined by Mike Mason, an aviation expert and human diver educator, to explore the often-overlooked complexity of human factors in high-risk environments. We dive into a reported incident involving an MQ-9 Reaper UAV crash and dissect the layers of context that often go unnoticed in simple “first stories.” Together, we discuss fatigue, local rationality, and the influence of organizational culture on decision-making in critical situations. What struck me in this conversation is how much we focus on blame rather than curiosity. Mike and I unpack the gaps in traditional incident reporting and the missed opportunities to learn, adapt, and grow. It’s a thought-provoking discussion on the messiness of real-world operations and why understanding the conditions that shape behavior is key to improving outcomes. 

 
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Ep. 6: Ben Goodheart and Gareth Lock

Today, I’m joined by Ben Goodhart, founder of Magpie Human Systems, a consultancy working in high-stakes industries like aviation, energy, and healthcare. In this episode, Ben shares some fantastic stories—from a near-disastrous glissade on a snowfield (while wearing crampons!) to a high-speed mountain bike crash that left him with a neck brace and a powerful reflection on risk. These stories are more than entertaining; they dive into the deeper questions of why we take risks, how we manage them, and what we learn when things don’t go as planned. We discuss the idea of risk not just as a negative concept but as a pathway to adventure, growth, and self-discovery. Ben brings fresh perspectives on the balance between control and surrender, the evolution of safety technology, and the ways adventure sports can teach humility, curiosity, and resilience. 

 

 
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Ep. 5: Ken Wylie and Gareth Lock

In this episode, I had the absolute pleasure of sitting down with Ken Wylie, an incredible adventure educator and risk management expert from Vancouver Island. We dive into one pivotal event—a tragic backcountry skiing accident—that shaped his perspective on risk, decision-making, and the social and psychological factors that influence our choices. Ken doesn’t just tell a first story, the surface-level narrative most of us default to—he unpacks the deeper, second story, challenging us to reflect on how we navigate uncertainty and growth in our own lives.

 
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Ep. 4: Abhijith Balakrishnan and Gareth Lock

Gareth and Abhijith delve into the complexities of maritime safety, focusing on the audit process and its implications. They discuss the dichotomy between first and second stories in safety management, emphasising how audits often fail to capture the true dynamics of operations at sea. The conversation highlights the challenges faced by auditors, the influence of regulations on safety practices, and the need for a shift towards a more nuanced understanding of safety that goes beyond mere compliance. Abhijith shares insights from his experiences in ship management and safety, advocating for a more holistic approach to auditing that considers the realities of the maritime environment.

 
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Ep. 3: Josh Bryant and Gareth Lock

Gareth and Josh Bryant talk through a hand-crush injury. The incident serves as a case study for exploring deeper causes of workplace events and shifting the focus from blaming individuals to understanding systemic factors. Josh details how the company responded to the event by implementing the “4Ds” (what's dumb, what’s difficult, what’s different, and what’s dangerous) as part of their operational learning. Josh emphasises the importance of learning teams, a method they adopted to foster open communication and understand the context behind worker actions. This approach led to a more positive safety culture and a shift from blame to curiosity. He also stresses the importance of safety not being proprietary and the need for sharing best practices.

 
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Ep. 2: Ron Gantt and Gareth Lock

Ron Gantt, HSE Director at Yondr and cohost of the Punk Rock Safety podcast, joins Gareth to explore how mundane work often masks complex systems with hidden risks. Ron shares his experience with a Midwestern utility company where trash collectors faced unrealistic safety policies, conflicting pressures like speed and customer service, and inadequate training, leading to an unstable and potentially dangerous work environment.

Ron highlights the importance of understanding worker adaptations as indicators of systemic issues and emphasises the need for deep, vertical audits that focus on understanding work as done rather than relying solely on broad compliance-based systems. 

 
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Ep. 1: Jayson Coil and Gareth Lock

This episode features a conversation with Jayson Coil, an Assistant Fire Chief and incident commander. Coil discusses the importance of understanding the “local rationality” or how seemingly irrational decisions made by people in complex situations often make sense within their own context. Jayson explains how the lack of personnel in critical support roles like logistics and planning, often due to competing demands from their primary employers, presents a significant challenge to wildfire management. Finally, Jayson highlights the importance of learning from past experiences, particularly by sharing tacit knowledge gained through experience and avoiding the tendency to simply attribute outcomes to luck or skill.

 
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