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

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

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

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

6. 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!

7. History of Human Performance

8. Nuclear Power Plants

9. Aviation Safety

10. Automotive Safety

11. General Industry
NOT
Enough!

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

13. Todd Conklin, Ph.D.

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

15. HOP – GE Businesses

16. HOP – Other Companies

17. Workers
Are Masters of
Complex Adaptive
Behavior… (Conklin)

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

19. Accidents are unexpected combinations of normal variability.
(Conklin)

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

21. 3 Parts of an Event
(Conklin) 21

22. 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

23. “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)

24. ...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.

25. 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)

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

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

28. Defenses Types of Defenses Strength of Defenses Layers of Defense
Sustainability of Defenses

29. 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:

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

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

32. Accountability Forward vs. Rearward

33. 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.

34. 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)

35. Operational Learning

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

37. 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.

38. 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

39. 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

40. 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

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

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

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

44. 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

45. 45

46. Recommended Reading “Pre-Accident Investigations” (Todd Conklin)
“The Field Guide
To Understanding
Human Error”
(Sidney Dekker)
“Managing The
Unexpected”
(Weick & Sutcliffe)
Bob Edwards / / C:
Check out Todd Conklin’s Podcasts