Let’s explore the process of rolling out Safety 2 in a large organization. My guests, safety experts Simon Bown and Adam Johns, shed light on the differences between traditional root cause analysis and the innovative learning review approach. Let’s delve into their perspectives and discover the key elements of a successful implementation. 

The Limitations of Traditional Root Cause Analysis

Adam Johns explains that traditional investigations, often driven by root cause analysis, focus heavily on individual wrongdoings and treat humans like machine parts. This reductionist approach neglects the broader context and fails to create psychological confidence and trust among staff members. 

The Learning Review Approach

Adam emphasizes that the learning review approach coupled with a just culture is essential for fair treatment of staff involved in events or mistakes. Instead of delving deeper into the individual’s actions, the learning review looks at the broader context of normal work and acknowledges that bad outcomes may not be solely attributable to bad actions. It uncovers a rich array of organizational and system-level learning that traditional investigations miss. 

Embedding Just Culture and Collaboration

Simon Bown adds that embedding just culture within the learning review process is crucial for its success. It requires collaboration between safety and HR departments to address conduct or capability issues while ensuring that the learning review process continues to identify valuable insights. Multi-departmental cooperation and reaching out to experts in the field contribute to a better and more effective implementation. 

Utilizing Expertise and Contextualizing

Both Simon and Adam stress the importance of seeking input from leading academics and experts to enhance the organization’s understanding and application of Safety 2. By combining their expertise with the organization’s unique context, a more comprehensive and valuable product can be developed. It is a continuous process of learning and improvement. 


Rolling out Safety 2 in a large organization demands a departure from traditional root cause analysis and a shift toward the learning review approach. By focusing on the broader context, embedding just culture, and fostering collaboration across departments, organizations can create a culture of continuous learning and improvement. Seeking expertise and contextualizing the approach ensures the development of a more effective and impactful safety system. Together, I strive for safer and more resilient work environments.