A team of county road workers was repairing a washed out culvert. They had one of their guys, who we will call Bill, down in the trench doing some hand shoveling work when part of the trench wall gave way and trapped his legs. His fellow workers quickly dug him out and had him taken to the hospital to be checked out. Fortunately, there were no significant injuries. However, everyone realized that this could have been an atrocious event. Many trench engulfment accidents cause major injuries and often times fatalities. The county leadership team wanted answers and they needed to know who was to blame for this event. In the discussion about the event, a good friend of mine who happens to be a councilman, thought it might be a good idea to have the county officials sit through a human performance presentation. Perhaps they would see that there were system weaknesses that needed to be corrected instead of looking for someone to blame and punish. When my friend approached his fellow county officials and presented this plan, they were willing to try it. I think most of them thought they already knew what to do; they needed to find out who screwed up and discipline them so that this sort of thing won’t happen again.