Human & Organizational Performance – H.O.P. Bob Edwards, M.Eng.

H.O.P. helps us improve our operational learning … … it’s not like a traditional program . . . Philosophy first…

H.O.P. improves our traditional programs by increasing our collaboration & deepening our operational intelligence.

Works hand in hand with our Management System’s approach to Operational Excellence: VPP (4 Elements) ANSI Z10 (PDCA) OHSAS 18001 (Risk Based & OE) Upcoming ISO 45001 (Similar to Z10) Internal System (i.e. Framework) ISO 9001 (Quality)

interested in learning! Our Goal with H.O.P. ... is to become a lot less surprised by human error and failure ... ... and instead, become a lot more interested in learning!

History of Human Performance

Nuclear Power Plants

Aviation Safety

Automotive Safety

General Industry NOT Enough!

Human Performance Performance Modes Operational Learning Systems Thinking Building Stronger Defenses (HF) Forward Accountability Better Collaboration Higher Reliability and Resilience (HRO)

Todd Conklin, Ph.D.

H.O.P. Implementation Process Leadership Commitment Selected & Trained Pilot Sites Implemented Learning Teams Developed Advocates / Coaches Created Centers of Excellence Shared Success Stories

HOP – GE Businesses

HOP – Other Companies

Workers Are Masters of Complex Adaptive Behavior… (Conklin)

Work as Planned vs. Work in Practice “Masters of the blue line” Normally Successful! (Conklin, 2012)

Accidents are unexpected combinations of normal variability. (Conklin)

combinations of normal variability. Success is also the unexpected combinations of normal variability. (Conklin)

3 Parts of an Event (Conklin) 21

bias our judgment of the pre-event context. 3 Parts of an Event The Challenge: Not to let post-event hindsight bias our judgment of the pre-event context. (Conklin) 22

“Underneath every seemingly obvious, simple story of error, there is a second deeper story. A more complicated story...a story about the system in which people work.” (Dekker, 2006)

...looked for root cause Our traditional approach... Event 5 4 3 2 1 Linear Approach Event Root Cause? 5 4 3 2 1 The problem is, the failure was not linear . . . . . . and there is almost NEVER one root cause.

Start back in process... ...move towards the event. Event Production pressure Fear of reporting Latent Conditions Inadequate defenses Many of the things that we find that led to the failure, were not identified in traditional hazard assessments! System Weaknesses Event Resource constraints Errors Hazards & Risks Flawed processes Local Factors Normal Variability System deficiencies Near Misses Design shortcomings Poor communication (Edwards/Baker/Howe, 2014)

The Pressure to Fix... ...Outweighs the Desire to Learn! Learning Information Best Solutions Response and Containment Event Time 26 26

Great performance is not the absence of errors. . . . . . it’s the presence of defenses. (Conklin, 2012)

Defenses Types of Defenses Strength of Defenses Layers of Defense Sustainability of Defenses

Layers of Defenses All Procedure Steps Critical Steps November 10, 2009 Layers of Defenses Example: Walking near a cliff Absence of barriers or fences Improve technique Taking extra care Pay attention Margin – proximity of treadway to edge All Procedure Steps Critical Steps All Risk-Important Actions Main chute fails to open 0.1% Fatality rate 0.001% Source: www.uspa.org

Sustainability of Defenses . . . and one year later . . .

We want to make it easier to do right than to do wrong!

Accountability Forward vs. Rearward

Beyond Taylorism Break the concept that the planner is smarter than the worker Bring the worker and planner together to create the plan Anticipate that human error will occur Expect operational drift Understand why the drift occurs Learn from “masters of the blue line” Learn from failure Learn from success.

Knows the most about the hazards. Sharp End Workers Highest Influence Over System Highest Injury Potential Front-line Supervisors Managers Leaders Company Knows the most about the hazards. Customers Regulators Blunt End (Conklin)

Operational Learning

“…you want to understand why it made sense for people to do what they did…in their context” (not yours!)… (Dekker, 2006)

Event Response Respond seriously and deliberately to events, near misses and good catches Remember, events are “Information Rich!” Promote a culture of learning & collaboration Learn before taking action Reduce operational complexity Fix processes and systems – NOT people.

The Learning Team Process Determine need for Learning Team 1st Session – Learning Mode only Provide “Soak Time” 2nd Session – Start in Learning Mode Define defenses / build new ones Tracking actions & criteria for closure Tell the story Hour long Soak time – overnight – “we couldn’t figure out how to do it…” – how many sessions Defenses – what do you want to do different? Crane story – crane program, not high risk – weak signal story – moving crane – put the letter in (used to be mad) Use your same crane actions Creates cultural confidence Freewill vs determinism – more influence than we think

When do we need to learn? Post-event (Injury/Quality/Operations) Near Miss or Close Call Good Catch Interesting Successes High Risk Operations Challenging Design Problems Anytime you can’t explain something 39

HOP is NOT engineering out the possibility of every mistake… …you cannot poka-yoke the world HOP is using many layers of defenses to build in space for mistakes

Safety Defined Safety is not the freedom from risk… ...it is the freedom from unacceptable risk. M. Bidez, 2013

When we believe we know the answer... ...we stop asking questions ...we stop listening ...we stop learning! 42

The power to ask the right questions... ...comes from acknowledging that you don’t know the right answer. 43

Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work. (Dr. James Reason) 44

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Recommended Reading “Pre-Accident Investigations” (Todd Conklin) “The Field Guide To Understanding Human Error” (Sidney Dekker) “Managing The Unexpected” (Weick & Sutcliffe) Bob Edwards / HOP_Coach@outlook.com / C: 423-280-821 www.hopcoach.net Check out Todd Conklin’s Podcasts