After the event · Learning from Emergent Outcomes
"Human error" is a label, not an explanation.
A three-day programme, built on the LFEO Learning Review, for people who lead reviews of events, good and bad. You will learn to look past the last action to the conditions that made it make sense, and to turn what you find into changes that reach the system.
Why reviews keep reaching the same conclusions
Outcomes emerge. They are rarely caused by one thing.
Most investigations work backwards from the outcome, find the person closest to it, and stop. The report names an error or a breach, recommends retraining or a new rule, and closes. The conditions that shaped the decision are still in place for the next team.
Outcomes in complex work emerge from the interaction of people, tasks, tools, pressures and the organisation around them. There is no single root cause to find. Learning means understanding those interactions from the inside, without the hindsight the reviewer brings, and doing the same for the things that go well.
The first story
The technician missed the check. The operator didn't follow the procedure. The supervisor should have stopped the job.
The second story
How did it make sense at the time? What was normal on other days, and what was different on this one? What did the system make easy, and what did it make hard?
The LFEO Learning Review
Four stages, so nobody rushes to the answer.
Most event discussions start in the middle. Someone tells the story, others say what they would have done, and within minutes there is a cause and a fix, usually landing on the person closest to the outcome. A clear shape slows that rush. Each stage has its own job, and the next one cannot do its job until the last has finished. Unlike improvement cycles that begin with a change to test, the review begins with an outcome you want to understand.
Stage 1
Prepare
Everything that happens before detailed questions are asked.
- Look after the people involved first
- Secure information before it disappears
- Decide the level of review needed
- Agree in writing what the review is for, and keep it separate from discipline
Within 72 hoursfor a serious event
Stage 2
Discover
The first story grows into one with context, and the timeline takes shape.
- Understand events from the view of those who were there
- Stay in learning mode, away from solutions and "why didn't you just..."
- Protect soak time, when details surface overnight
Within 21 daysthe story is shared back with those involved
Stage 3
Synthesise
From what happened to why it made sense at the time.
- Those involved check the timeline first
- Look across PETTEOT, time, and work as imagined versus work as done
- Ask what was working well, and where capacity came from
- Develop proposals with the people who do the work
Within 90 daysa draft report for those involved to comment on
Stage 4
Embed
Proposals become changes, and the story travels.
- A separate group decides which changes to take forward, and owns them
- Actions are tracked to closure
- The story is shared in stages, with identifying detail removed at each step
After 3 to 6 monthsa check on whether the change worked
↻ What the check finds feeds into how the next review is prepared, turning four stages into a cycle rather than a line.
PETTEOT: what to look at
- Person
- Environment
- Tasks
- Tools and technology
- External influences
- Organisation
- Time
Three levels of review
The same four stages, scaled to the event.
The four stages work for a five-minute team debrief and for a review that takes months. What changes is the depth, the time and the skill needed to keep the conversation psychologically safe.
Level 1
Team debrief
Minutes, straight after the task, using four questions: what did we expect, what actually happened, what shaped the difference, and what will we keep or change next time?
Who runs it anyone on the team
Level 2
Small Learning Team
Two short sessions with a night of soak time between them, for an event worth deeper learning where nobody was seriously hurt and the accounts broadly agree.
Who runs it a trained facilitator who was not involved
Level 3
Full LFEO Learning Review
For events involving harm, hierarchy, conflicting accounts, confidentiality concerns, possible consequences for jobs or organisations, or strong emotion.
Who runs it trained and experienced facilitation
A Level 2 review can become a Level 3 when something new surfaces. When that happens, the right move is to pause, protect the people involved and bring in more support. That isn't the review failing. It is the review doing its job.
The programme prepares you to run Level 1 and Level 2 reviews, and to know when a Level 3 review is needed. For Level 3 events, see Investigations and advisory.
What you will cover
Three days that follow the review itself.
The programme follows the four stages of the LFEO Learning Review, with short inputs and a lot of practical work on real cases from defence, energy, healthcare and other high-risk settings. You will also learn the seven phases of a Learning Team and when to choose other methods.
Day 1 · Prepare
The conditions behind outcomes
- Why outcomes emerge from ordinary conditions
- PETTEOT, time, and work as imagined versus work as done
- Sensemaking, bias and the language that closes inquiry
- Barriers and the capacity to fail safely
- Protecting people and information, and choosing the level of review
Day 2 · Discover
Gathering the second story
- Holding the first story loosely
- Better questions and interviews that invite honest accounts
- Collecting data before it disappears
- Building timelines and working with conflicting stories
- Keeping a Learning Team in learning mode
Day 3 · Synthesise and Embed
From understanding to change
- Local rationality and what was working well
- What needs to change, and what you can change
- Who the learning is for, and learning products that reach them
- Tracking actions and sharing the story in stages
- Choosing a method: Learning Teams, LEODSI with PETTEOT, AcciMaps and barrier analysis
What you will be able to do
Lead reviews that change how work gets done.
By the end of the programme you will have a method you can use on Monday, and the language to explain it to your leadership team.
- Oversee a review process that is proportionate to the severity of the event and fits your organisation's guidelines.
- Lead a review that identifies the conditions behind an event and produces recommendations that change them.
- Create an environment where people can raise error-likely situations and near misses without fear of retribution.
- Lead and influence the change needed for learning to happen across your team or organisation.
Format and price
Who it is for, and what it costs.
Who should attend
- Safety, HSEQ and assurance managers
- Investigators and review team members
- Supervisors and team leaders who run debriefs
- Training managers who turn lessons into practice
- Senior leaders who commission reviews and act on them
Learning from Emergent Outcomes
£1,500
per person, for three days. Group rates are available, and the programme can be run in-house for your team.
- Three days of facilitated learning on real cases
- Tools and templates to use in your own reviews
- A certificate of completion for your CPD records
The book behind the programme
Learning from Emergent Outcomes
When something goes wrong, the first question is often “who messed up?”
The book sets out the LFEO Learning Review in full, with the conditions to look for, the questions to ask, and worked examples of Learning Teams, LEODSI with PETTEOT, AcciMaps and barrier analysis. Its stories come from diving, and the method applies to any team that works with risk. Pre-orders open in November.
Gareth Lock MSc
Register your interestBook a call
Start with a curious conversation.
Tell us what is happening in your organisation, what you have already tried, and what you would like to be different. We will be honest about whether we can help, and point you elsewhere if someone else would serve you better.
Prefer email? Write to [email protected] and we will reply within two working days.