On September 29, 2017, Lt. General Jay B. Silveria, Administrator of the United States Air Force Acadamy gave the entire organization a chance to improve - he could have punished, he could have sough revenge, he could have responded entirely emotionally - but he chose not to...he chose to respond by improvement.
When something bad happens leaders can either blame and punish or they can learn and improve.
Here is what learning after a serious violation of policy sound like. Listen carefully - its worth your time.
Best Safety Podcast, Safety Program, Safety Storytelling, Investigations, Human Performance, Safety Differently, Operational Excellence, Resilience Engineering, Safety and Resilience Incentives
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PAPod 569 - PART TWO: 11 Seconds: How a System, Not a Nurse, Failed
Part two of the RaDonda Vaught story examines what emerged after the event: inve
PAPod 568 - PART ONE: Charged for a Mistake: The Nurse, the Error, and a System That Failed
In this episode, nurse RaDonda Vaught tells the detailed, context-rich story of
PAPod 567 - Open Questions 2025: From Metrics to Monitors — Rethinking Safety
Episode: an extended open Q&A from the Pre-Accident Investigation Conference in
PAPod 566 - Blame Stops Improvement: How Blame Silences Learning
Todd Conklin explores how blame shuts down learning and prevents organizational
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