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Full webinar

About the Session: When incidents are blamed on “human error,” organizations miss the deeper lessons hiding beneath the surface. The Human Error Triangle reframes failure by identifying three overlapping conditions that make mistakes inevitable: Rarely Touched Areas, New Personnel Involvement, and Time-Based Pressure. In this session, Melissa Davis shares a practical framework developed through her work leading root cause and preventive action programs in complex technical environments. Participants will learn how to detect risk patterns before metrics expose them, recognize how systemic factors shape human behavior, and replace blame with curiosity. The Human Error Triangle helps teams see where people are most vulnerable, and how small design, training, and communication shifts can prevent bigger failures. Attendees will walk away with tools to apply immediately in retrospectives, team meetings, and performance conversations to strengthen both people and systems. Learning Objectives: By the end of this session, participants will be able to: Identify the three conditions that increase the likelihood of human error. Analyze recent challenges or failures through the Human Error Triangle lens to uncover systemic contributors. Facilitate non-blaming conversations that shift focus from individual mistakes to organizational learning. Develop targeted interventions to reduce pressure and support new or infrequently used processes. Interactive Session Information: The interactive portion of this session, “Map the Triangle,” invites participants to apply the Human Error Triangle to real-world challenges from their organizations. In small groups, attendees will: Identify a recent “human error” event or near miss. Map the situation to the three points of the triangle — Rarely Touched Areas, New Personnel Involvement, Time-Based Pressure. Discuss which factors were present and how they interacted. Design one small, realistic intervention to reduce risk in their environment. Each group will share its key insight during the debrief, highlighting common conditions across industries. This activity fosters empathy, collaboration, and systemic thinking — transforming the idea of “human error” into a shared opportunity for prevention and better design. Participants leave with a ready-to-use facilitation exercise they can bring back to their own teams. About the Facilitator: Melissa Davis is the founder of SystemSense, a consulting practice dedicated to uncovering the hidden systems behind human behavior and organizational performance. She is the creator of the Human Error Triangle, a framework that helps teams identify the conditions that make mistakes inevitable — and design environments where people can thrive. Drawing from years of experience leading root cause and preventive action programs in complex technical organizations, Melissa’s work bridges people, process, and system design. Her approach combines compassion with clarity, helping leaders replace blame with insight and turn recurring problems into opportunities for systemic improvement.