But it's rarely enough.
Ask what made the work difficult.
What changed.
What information was available.
What people were trying to achieve.
What they normally do.
What made this time different.
Better questions reveal more of the system.

It's not always the wrong question.
Start a conversationIt's not always the wrong question.
01 / INSIGHTSAsk what made the work difficult.
What information was available.
What they normally do.
Better questions reveal more of the system.
A bowtie with eight controls doesn't necessarily provide eight layers of protection.
The people doing the work encounter everything the procedure couldn't anticipate.
But where work itself is creating harmful exposure, support isn't enough.
You don’t need to know which service you need. We’ll start with the problem.