PreAccident Investigation Podcast PAPod 592 - How a Near-Miss Sparked the Learning Team Movement
Apr 4, 2026
A near-miss with an arcing wrench kickstarts a story about shifting from blame to learning. A mixed group of workers gathers to identify what really needs to be learned. The conversation highlights using focused questions, better data, and system-level solutions. The approach spreads across the lab as a fast tool for operational improvement and prevention.
AI Snips
Chapters
Transcript
Episode notes
Postdoc Wrench Arc Near-Miss That Started Learning Teams
- Todd Conklin recounts a Los Alamos near-miss where a postdoc dropped a crescent wrench into a battery bank, causing a dangerous arc while solo in the field.
- The postdoc self-reported the incident after taking electrical safety class, sparking the response that birthed learning teams.
Workers Led The Inquiry Instead Of A Formal Investigation
- Todd describes assembling a diverse group (postdocs, PIs, a group leader) into a conference room to ask what they needed to learn instead of launching a punitive investigation.
- He stepped back from facilitation so the workers could surface latent system issues and training gaps.
Solving System Problems Beats Fixing One Event
- The learning team shifted focus from the single near-miss to systemic gaps in the postdoc professional development and mentorship structure.
- That broader framing revealed latent conditions so clear the corrective actions 'wrote themselves.'