ABSTRACT
Blame, accountability, culpability, and fault are outcomes that exist after the learning has happened. Once conditions are identified and understood, and the process of learning how the event happened can begin in earnest for the organization. Understanding what is happening while it is happening is the primary requirement for successful learning to occur. Improvement is always a function of learning. Learning makes safety professionals more prepared to understand and facilitate decision-making. Learning makes them smarter. Many of safety professionals and probably all the individual members of their executive leadership team have their personal and professional worth determined by the outcomes of their safety and reliability programs. There is a profound difference between measuring and understanding outcomes versus measuring and understanding processes of doing work. Think of this problem in as simple terms as the difference between system outcomes and system performance.
